CERTIFIED NURSING ASSISTANTS

Do you enjoy helping others?

Do you enjoy spending quality time listening to stories of long ago while helping someone brush their hair? C.N.A.’s spend their day caring for people and helping them with the daily care functions such as bathing, dressing and eating.

Our program is designed to teach you the fundamentals of nursing. C.N.A.’s are the core of any successful nursing team. Our instructors will provide you the individual education needed to help you not only pass the Indiana State exam but be a mentor to you throughout your career.

To begin your rewarding career on the journey of nursing, all you need to do is:

Complete our accredited nurse aide class.
Pass the written and skills test on the state competency evaluation.

To Register, complete the form below:

Name *

First

Last

Other names used

Full Address *

City, State, Zip *

Email *

Phone Number *

Date of Birth *

Social Security Number *

Class Interested In: *

Payment Source *

Emergency Contact Name and Phone Number *

Name of long term care facility currently employed *

CNA Registry Number if applicable

Has any disciplinary action ever been taken against you regarding any health license, certificate, registration or permit you hold in any state? *

Do you have any pending criminal charges other than minor traffic violations? *

Yes
No
Other

1110 + 995 = *

2105
1875
695
1895

120-80 = *

7+50 = *

90-42= *

Read the following paragraph then answer the questions following. Choose the best answer. The fastest growing segment of the population in the United State is the elderly. Because of the medical advances people are living longer. Certified nursing aides provide most of the direct personal care to the elderly residents. A nurse aide helps in feeding, bathing and dressing residents, as well as many other tasks. The nurse aide can be the resident's best friend. What is the fastest growing segment of the population? *

Young Adults
Eldery
Middle-aged people

Who provides most of the direct care to the elderly in long-term care facilities? *

Doctors
Nurses
Certified Nursing Assistants

I authorize the Institute of Caring to share my contact information with 3rd party agencies, such as the Indiana Department of Workforce One, Ivy Tech, Indiana State Department of Health, etc. *

I authorize the Institute of Caring to share my photo on social media and webpages. *

In consideration of allowing me to participate in training, I, the undersigned participant (or parent or legal guardian if a minor) do hereby waive liability, release, and forever discharge The Institute of Caring, L.L.C., and any of each of their affiliates, officers, agents, employees, and representatives, from any and all claims, demands, rights, and causes of action, of whatever kind or nature, arising out of all known and unknown, foreseen and unforeseen bodily and personal injuries, damage to property and the consequences thereof, including death, resulting from my voluntary participation in the training. I have voluntarily and knowingly agreed to participate in the training and do hereby assume all responsibility for my participation and activities in such training. *

I agree
I disagree

Signature/Date *

The Institute of Caring training program does not discriminate because of age, disabled, race, color, national origin, religion, sex, disability or being a qualified disable veteran or qualified veteran or the Vietnam era or other category protected by law. I hereby affirm that the information provided on the application is true and complete. I understand that any false or misleading representation or omissions made on the application may disqualify me from the training program. I hereby authorize persons such as the Institute of Caring, my employer, and other organizations to provide requested information regarding my application, and I completely release all such persons or entities from any and all liability related to the providing and use of such information. I understand if selected for the Institute of Caring training program, I will be required to submit to a drug screen prior to the commencement of clinical, if required by the clinical site. I understand if selected I may be removed at any time from the training for any reason with or without notice/cause.

Signature/Date *

By signing this acknowledgement form, I confirm that I have read the information and policies of the program. Any questions I had have been answered. I agree to comply with the information and policies and have received a copy of them as well as the well as the course outline. I also understand failure to comply with these policies may result in my removal from the Institute of Caring QMA Training Program and possible future opportunities to participate.

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