Certified Nursing Assistant

APPLICATION FOR ADMISSION Name (First) (Last) Date of Birth Home Address: City Zip code Phone # (home) (cell) Email Address: How did you hear about us? COLORADO MEDICAL HEALTH TRAINING AND COLORADO NURSES AIDE SCHOOL NURSE AIDE PROGRAM Social Security Number

APPLICANT EDUCATION Dates Name and Locaon of Educaonal Instuon/School Specialty, Cerﬁcate, Diploma APPLICANT EMPLOYMENT EXPERIENCE Dates Name and Locaon where Employed Dues SPECIAL TRAINING IN HEALTH CARE FIELDS Dates Name and Locaon of Training Classes Specializaon EXPERIENCE IN HEALTHCARE FIELDS Dates Any Healthcare Experience Dues From To From To From To From To From To From To

Are you able to perform the essenal job funcons required for this profession? Are you a Cizen, or Legally Authorized to work in the U.S.? Have you ever been convicted of a Misdemeanor or Felony? If yes, please provide dates, and explanaon in details of any convicons including City/State: BACKGROUND RESEARCH RELEASE Please read this secon carefully and acknowledge your understanding and acceptance by signing below. I cerfy that all the following statements are true, correct, and complete to the best of my knowledge. Consent to conduct Background Invesgaon As a condion of, and in consideraon for, admission to the Nurse Aide Program at Colorado Nurses Aide School, I give my permission to invesgate my personal and employment histories and criminal background. I understand that this background invesgaon will include, but not limited to, veriﬁcaon of all provided informaon, criminal and driving record, interviews past employers and listed references Cooperaon with Invesgaon I agree to cooperate with all background invesgaons deemed necessary or required and to sign any waiver or releases that may be necessary to obtain access to my personal informaon. Falsiﬁcaon Statement From To YES No YES No YES No

I understand that any falsiﬁcaon and/or omission of fact made by me in this applicaon or in connecon with any background invesgaon may be suﬃcient grounds for rejecon of this applicaon for admission, or if discovered aﬅer admission, for immediate dismissal from the Program. Applicant Signature: Date:

Other Do you have any liﬅing restricons or physical limitaons? If YES please provide details Vaccines required by the clinical praccal site  Tuberculosis skin test (1 step) /Chest x-ray/blood TB test  Flu Vaccine (Sept.-May)-OK to WAIVE/EXEMPT  Covid Vaccine- OK to WAIVE/EXEMPT  Covid booster- OK to WAIVE/EXEMPT *****Please give vaccine proof to the school staﬀ Signature: YES No

TUITION AGREEMENT Approved and Regulated by the Colorado State Board of Nursing General Information Date Student’s Name Program/Course: C N A / Nurse Aide Program Start Date Date paid in full Method of payment . Tuion is $ 1200.00 due at the me of registraon if paid in full. Or A payment plan is available if needed at $ 1500.00 and will follow the below schedule We accept cashier check, money order and credit card (small fee applied). PLEASE NO PERSONAL CHECKS OR CASH ACCEPTED. Deposit due at registraon $500.00 Due now 2 nd payment due 1 st week of class $500.00 Due : 3 rd (last) payment is due 2 nd week of class $500.00 Due: To remain in the program your payment must be paid mely and a $20 late fee will be applied for each day that it is late

1. TUITION includes: Textbook Colorado Background Check Online or in person theory and hands-on praccal labs at the facility Clinical rotaon in a nursing home/care center Professional Liability Insurance and Worker’s compensaon insurance By signing below, the student agrees to pay Colorado Nurses Aide School the total stated tuition. The School agrees to provide the occupational training in accordance with the provisions of the school policy listed in the student handbook. Payment of all monies due shall be a condition of continuing enrollment. Upon sasfactory compleon of all academic and skill requirements and when all ﬁnancial obligaons to the School have been met the School will award the CERTIFICATE to the student. The student and school understand that this Tuion Agreement, WHICH INCLUDES THE REFUND POLICY, may not be amended except in wring and signed by both pares. Postponement of starting date, whether at the request of the school or the student, requires a written agreement signed by the student and the school. The agreement must set forth: a.) Whether the postponement is for the convenience of the school or student; and, A deadline for the new start date, beyond which the start date will not be postponed . Refund Policy-******The refund is based on if the tuion has been paid in full. Students not accepted into the school are entled to all moneys paid. Students who cancel this contract by nofying us in wring within three (3) business days before the ﬁrst day of class are entled to a refund minus a $500.00 deposit. In the case of students withdrawing aﬅer commencement of classes, the refund table below will apply. The refund is based on if the tuion has been paid in full. Refund Table  Student is entled to upon withdrawal/terminaon* o Refund Refund on the 1 st day of the start of the class 50% + minus deposit On the 2 nd day of class there is NO REFUND 0%

1. The student may cancel this contract at any me prior to midnight of the third business day aﬅer signing this contract. 2. All refunds will be made within 30 days from the date of terminaon. The oﬃcial date of terminaon or withdrawal of a student shall be determined in the following manner: a. The date on which the school receives wrien noce of the student’s intenon to disconnue the training program; or b. The date on which the student violates published school policy, which provides for terminaon. c. Should a student fail to return from an excused leave of absence, the eﬀecve date of terminaon for a student on an extended leave of absence or a leave of absence is the earlier of the date the school determines the student is not returning or the day following the expected return date. 3. The student will receive a full refund of tuion & fees paid if the school disconnues a course/ program within a period of me a student could have reasonably completed it, except that this provision shall not apply in the event the school ceases operaon. 4. The policy for granng credit for previous training shall not impact the refund policy. I CAN FIND A COPY OF THIS TUITION AGREEMENT AND A CURRENT STUDENT HANDBOOK.VIA THE WEBSITE WWW.MEDICALHEALTHTRAINING.COM Student Signature Carolyn Omiteru School’s Oﬃcial Colorado Nurses Aide School

Attendance Policy This is a setting for adult learners. That being said, we expect you to conduct yourselves like adults during our time together at the Colorado Nurses Aide School / Nursing Aide Program. This means that we expect you to arrive to class on time. If you are going to be late, please text or call your instructor (phone numbers will be provided). If you are going to be absent please call or text your instructor. It is your responsibility to make up missed assignments and tests. If you miss one (1) class, you will be asked to retake the course at the next time the course will be offered. If you are going to be late for lab, please text or call your instructor. Missing lab is not an option. This is where all of your hands-on experience happens. If you miss a lab, you will need to make it up at another time when lab is offered. Drugs and Alcohol Policy If you come to school or clinical smelling like alcohol, marijuana or are suspected to be under the influence of any behavior-altering substance, you will be asked to leave. The school setting is a professional area and you should conduct yourself accordingly. The above information has been explained to me. I understand my responsibility as a student at the Colorado Nurses Aide School and the consequences should I not fulfill my responsibility. CONFIDENTIALITY STATEMENT As a student of Colorado Nurses Aide School / Nurse Aide Program, I realize that while working in any health care facility during the program as part of my assigned clinical experience, I am dealing with confidential information and communications. I understand, that information about clients/residents, their families, diagnosis and treatment, financial situation, as well as employees of the facility, staff, and faculty during the course of study is to be discussed only in accordance with my professional responsibilities. I shall not discuss any information in the provision of care in any other manner. I understand and assume my responsibility to protect the rights of patients, their families, all employees of the facility, staff and faculty by maintaining confidentiality of communication. I am aware that violation of the above agreement will be grounds for probation or dismissal as determined by program instructor, program coordinator and school administration. Signature Date

COLORADO NURSES AIDE SCHOOL STATEMENTS REGARDING HEALTH AND SAFETY Student Name: 1. I agree to submit to alcohol/drug tesng at my expense if requested by my clinical instructor for suspicion of being under the inﬂuence of alcohol or drugs in the clinical seng. I understand that failure to do so will result in disciplinary acon. 2. I have been given informaon regarding hepas B and Hepas B vaccine. I understand that due to my occupaonal exposure to blood or other potenally infecous materials, I may be at risk of acquiring hepas B (HBV) infecon. I have the right to waive this tesng for personal reason. 3. I have personal health insurance coverage with the following company: , or 4. I do not have personal health insurance coverage at this me, and understand that I am liable for costs of any treatments given as a result of any accident/injury at the Colorado Nurses Aide School or clinical facility. 5. My health history shall be in the custody of the Colorado Nurses Aide School: a) I shall submit the Lab tests (Covid -19 rapid test) if required by the clinical aﬃliate; TB test (1 step) is required. Covid vaccine and ﬂu vaccine may be required especially during ﬂu season (Sept- May) b) I shall submit x-ray report if my TB test was posive;

c) My health history and results of required tests may be released to any clinical aﬃliate to which may be assigned. 6. I understand the clinical poron of the program is a vital component of the program. If I have been denied access to the clinical area related to a criminal record or have posive drug screen, I understand I will be unable to complete the Program. Skills & Praccal Experience Subject Release Form I, (student name) give my permission to be the lab skills and praccal experience subject for the Colorado Nurses Aide School Program. I understand that if, while being an actor/pracce object, quesonable appearances (such as abnormal Vital Signs, weight, pain, discomfort, etc) are noted by the instructors, I will seek my own medical aenon and advice as suggested by the Nurse Aide instructor. I further release Colorado Nurses Aide School of any responsibilies for any and all physical or mental condions, which may be believed to have resulted from any praccal sessions, where I was ulized as an exam subject. I further agree to monitor the me I was examined and to complete accurate me reporng sheets as directed by the CNA instructor(s) if applicable. I verify that I have read and understand the items above. Signature: Date:

PHOTO RELEASE FOR SOCIAL MEDIA AND GROUP CHAT FORM AGREEMENT This Media Release Form (the “Form”) is eﬀecve and agrees to the terms below: 1. The Party grants permission to Colorado Medical Health Training/ Colorado Nurses Aide School to use your photographs on Company social media accounts including Facebook, Instagram, Tik Tok and Twier/X and on the Company website, without acknowledgment or recognion given to the Party. 2. The Party grants the Company creave permission to alter the photographs, permied that the photographs are not altered in an explicit manner or cause malicious representaon of the Party and their associates. 3. The Party consents any third party (including any agency, client, publicaon or other organizaon or instuon) in whole or in part, for distribuon or sharing of the photographs on their social media accounts, for the purpose of publicity and promoon of the Company. 4. In giving this consent, the Party releases the Company from liability for any violaon of any personal or proprietary right the Party may have in connecon with all third pares’ use of the images on social media. 5. The Party allows the Company to send you messages in the group chat that contains informaon about school’s acvies, upcoming events and other relevant informaon. 6. The Party cerﬁes that they are 18 years of age or 16 with the consent of the legal guardian. I want to OPT out social media/photos OR group chat (Check one or both) IN WITNESS WHEREOF, the Party executes this Form by signing below. Print Name and Signature Legal Guardian Name and Signature , by who acknowledges

Contact us

Curriculum

CNA Application Forms

Please fill out the enrollment form completely. If a question does not apply, enter “NA”. Once finished, click “SUBMIT” on the last page. If you have issues encountered, please email carolyn@medicalhealthtraining.com with details

2 Comments

Leave a Reply Cancel reply

Modal title