Morning	Evening

NURSE ASSISTANT APPLICATION

First Name_______________________________ Last Name _______________________________MI ____

Address__________________________________Apt. #_____ City ________ State _____ Zip _________

Contact Number ________________________ E-mail Address _________________________________

Date of Birth ______/_______/_________	Social Security Number _______-______-____________

NA Program Start Date: ______________________	How did you hear about us? ________________

Student Aid:

Department of Rehabilitation

Veterans Administration (VA)

Workforce ______________(Which _County)

CalWORKs

Self-pay	Other ____________________

Are you interested in the Home Health Aide Program? Have you passed the TABE placement Test?
Do you have an American Heart BLS CPR Card?

___Yes	___No

___Yes	___No When? ______

___Yes	___No

Are you aware of any current or past medical, physical or emotional problems that will keep you from completing the Nurse Assistant Program?	____ Yes	___ No

If yes, briefly explain_____________________________________________________________________

I understand that I am NOT “OFFICIALLY” a Nurse Assistant student of Clovis Adult Education until I receive an “Acceptance Letter” of admission, attend the Mandatory Orientation and pay my program fee. ______ (initial)

I understand that my signature confirms all the above information is true.

________________________________________________ Signature

_____________________ Date

OFFICE USE ONLY

READING

MATH

Score

_________

_________

Date taken

__________

__________

NOTES: ________________________________________

_______________________________________________

Picked up Acceptance Letter __________________

Revised 12.14.22 fq