Application for Admittance to CNA Training Academy Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Date of Birth * Are you at least 16 years old or older? * Yes No If No, Parental or Guardian authorization required. Have you ever been CNA or HHA or CMA? * Yes No If yes, Date and State: Have you ever been convicted of a felony? * Yes No If Yes, explanation: Course Requested: * CNA/HHA CMA ACMA Time Requesting * Days-Mon-Fri-8am-3pm Evening-Mon-Fri-5pm-11pm Weekends Sat-Sun-9am-3pm Which Dates Requesting? * 08/11/2025-09/03/2025 09/08/2025-10/01/2025 10/06/2025-10/29/2025 11/03/2025-11/26/2025 12/01/2025-12/24/2025 12/29/2025-1/21/2026 I understand CNA Training Program is a 3 week course consisting of CNA-75hrs/HHA 16hrs. * Agree Disagree I understand the Tuition for course MUST be PAID IN FULL before exams will be scheduled. I further understand all monies paid are NON-REFUNDABLE. * Agree Disagree I understand if I fail the exam, I must pay to retake the exams. * Agree Disagree I attest that all the information I have provided CNA Training Academy is true and accurate. I further acknowledge any false or misleading information will prevent my addmittance to CNA Training Academy. I further understand, if I receive a unacceptable background check I will not be allowed to proceed with classes. * Agree Disagree I understand if accepted to CNA Training Academy, I will follow all rules and respect the other students and teachers. Failure to act acceptably will result in expulsion from CNA Training Academy. I further understand during Clinicals I will adhere to the rules and regulations of the facility clinicals are being held and will act will respect and dignity for both CNA Training Academy and the facility and their resident. Failure to do so will result in expulsion without refund and You will NOT be allowed to proceed to the exams. * Agree Disagree Signature * Date MM DD YYYY Thank you!