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CNEI CNA Application Form

160 Hour Certified Nurses Assistant Certification Course

The 160 Hour CNA Class Consists of Everything you will need tfro the state exam and to complete the program. 60 Hours of theory study at CNEI. 100 Hours of clinical experience at CNEI clinical sites. You will be provided with tow uniforms, one gate belt, one stethoscope and one blood prissure cuff. Your are provided a certificatg of completion upon suscessful completion of the training program. State exam for theory and clinical is conducted at the school.

In order to attend classes, you must be able to supply the following:

1) Two forms of identification (Drivers's license and social security card)
2) High school diploma or GED.
3) Your payment of $2801.50, cash, check, credit card (Visa aor MasterCard)

A non-refundable deposit of $100.00 is necessary in order to hold a seat for the class.

Social Security Number (SSN) _______ _ _________ ( will be add manually at the school) Do NOT instert her.

Name(Required)

First Middle Last

Date of Birth

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone

How did you hear about CNEI?

Age

Citizenship

Universities that are recipients of federal dollars are required by the Federal government to solicit certain demographic information to meet federal reporting requirements. Applications are requested to provide the following information voluntarily. This information will not be utilized in a discriminatory manner.

Citizenship Status

Citizen

Permanent Resident

Other

Demographics

Race / Origin

Gender

EMERGENCY CONTACT

In the event there is an emergency on your behalf and we need to contact someone for you, please provide 2 contacts

Emergency Contact #1(Required)

First Last

Relationship to applicant

Phone(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Emergency Contact #2(Required)

First Last

Phone(Required)

Relationship to applicant

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Military

Are you a veteran of the U.S. Military?

High School Information

Do you have a High School Diploma or GED

High School Name

Graduation Date or Expected (Month/year)

High School Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

College Information

Jr College Name

Dates Attended

Achievement (Diploma/Cerificate)

Other Training (Graduate, Technical, Vocational)

Dates Attended(Required)

Achievement (Diploma/Cerificate)

Awards, Honors or Special Achievements received

What aroused you interest in the medical field?

Questions

Does the sight of blood and/or other bodily fluids make you feel uneasy(Required)

Are you sensitive to the needs of others?(Required)

Do you have children or anyone in your home who will require daily care?(Required)

If yes: Have you made arrangements for the child/adult care(Required)

Transportation is a significant factor in getting to required classes and clinical sites safely and on time. Do you have reliable transportation?(Required)

Are you currently working?(Required)

If you are working where?(Required)

What is your current job title?(Required)

How many hours do you work each week?(Required)

Have you ever worked in the medical field?(Required)

If yes, please explain?(Required)

This program requires approximately 30 hours per week of attendance not including homework or projects. Do you agree that you will dedicate at least 30 hours a week for classroom and clinical time?

Is your employer willing to arrange your schedule around the required classroom and clinical time?

If yes, please explain.

This training program requires certain physical abilities in the clinical portion. Do you have any restrictions that would limit you from full participation in clinical training?

Background

If your records have been expunged pursuant to applicable law, you are not required to answer yes to the following questions. If you are unsure whether to answer yes, we strongly suggest that you answer yes and fully disclose all incidents to avoid any risk of disciplinary action or revocation of your offer of admission.

This training program requires a criminal background check. Have you ever been charged with a Felony or Misdemeanor:

If yes, please explain.

Do you have any additional comments not covered by the questions above?

Please attach a photo High School Diploma or GED.

Accepted file types: pdf, doc, docx, jpeg, Max. file size: 10 MB.

Agreement

I understand that this application is for admission only for the term indicated. I agree that I am bound by the School's regulations concerning application deadlines and admission requirements. I agree to the release of any transcripts and test scores to this institution, including any SAT, Achievement Test, and ACT score reports. I certify that this information is complete and accurate. I understand that making false or fraudulent statements within this application or residency statement will result in disciplinary action, denial of admission and invalidation of credit or degrees earned. If admitted, I agree to abide by the policies of the School. Should any information change prior to my entry into the University, I will notify the Office of Admissions. I understand that the application fee I submit with this application is a non-refundable fee.

Signature to be signed during interview (Leave blank for now)_______________________________________________________________(Required)

Date / Time(Required)

Do you understand and agree to the terms listed above?(Required)

Yes, I understand and agree to the terms listed above.

Comments

This field is for validation purposes and should be left unchanged.

CNEI CNA Application Form

CNEI CNA Application Form

160 Hour Certified Nurses Assistant Certification Course

In order to attend classes, you must be able to supply the following:

A non-refundable deposit of $100.00 is necessary in order to hold a seat for the class.

Social Security Number (SSN) ___________ _______ ___________ ( will be add manually at the school) Do NOT instert her.

Citizenship

Demographics

EMERGENCY CONTACT

Military

High School Information

College Information

Questions

Background

Agreement

Social Security Number (SSN) _______ _ _________ ( will be add manually at the school) Do NOT instert her.