Name:(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Cell Phone:(Required)

Personal Email Address (Not School or Work):(Required)

Emergency Contact Name:(Required)

First Last

Emergency Contact Phone:(Required)

Preferred Class Start Date:(Required)

Course Number if known. (Course Number can be found at the top of the Course Schedule)

Preferred Class Time:(Required)

Day

Evening

Do you have any lifting restrictions?(Required)

Yes

NOTE: If Yes, a doctor’s release is required.

Please list any allergies you have:

TB TEST REQUIREMENTS: All students are required to provide proof of a TB test. 2-Step TB testing takes a FULL 14 days and must be completed prior to the start of clinicals. TB testing can be completed free of charge at Hope Health. A QUANTIFERON blood test result can be done in place of the 2-Step TB test.

Do you agree to have TB testing/QUANTIFERON testing completed before the start of clinicals?(Required)

Yes

Media/Photo Release: Throughout the training program, the instructor will take pictures of the students practicing skills and a graduation photo at the end of the course. These photos are featured on the facility social media pages and website.(Required)

I agree to have my photo shared and posted.

I choose not to have my photo posted or shared but understand it is my responsibility to ensure that I am not included in photos taken during class or graduation.

Payment Options
The Hope Nurse Aide Training Program tuition cost is $600 which includes 81 hours of supervised classroom, lab and clinical training, instructional materials, textbook and background check. The state exam fees are not part of the training program. $131.25 for the state exams fees is due at the last day of class. Students that withdraw from the program seven [7] or more days before the program will receive a full refund or payment made. Students that withdraw six [6] days to three [3] days before the start of the program will receive a partial refund of $200. For a course withdraw of less than [3] days or for any student that is a “No Show” at the first day of class (online or in-person), the student or sponsoring organization will not receive a refund. Students that fail to complete ALL the required assignments by the dates outlined on the schedule will result in a withdraw or failure of the course and the student or sponsoring organization is not eligible for a tuition refund.

Payment Options(Required)

Personal Check or Money Order

Voucher – DVR, ADVOCAP

Employer/School

Please select the payment option that works best for you.

Please enter the name, phone number and email address of the Employer/School representative if that payment option is selected.

Billing
An invoice will be sent to the email address given in this application. If a payment plan is requested, the student must reach out to Julia at jschramek@hopehealthandrehab.com requesting installment billing. Payment is due upon receipt of invoice and a class seat will not be held until payment is received.

Applicant Statement
By summitting this application, I certify that all information listed is complete and accurate to the best of my knowledge. I understand that if any information provided is false, I may not be eligible to participate the Hope Nurse Aide Training Program.

Applicants under the age of 18, check here. A Parent/Guardian consent form will be emailed to you.

Applicant under 18

Contact Info

CNA Class Application