CERTIFIED NURSING ASSISTANTS

Name *

First

Last

Address *

Phone Number *

Email *

Emergency Contact *

Current employer and position *

Which program are you interested in purchasing? *

CNA - $1,325.00
QMA - $1,525.00

Which sessions do you plan on attending? *

Spring
Summer
Fall
Winter

Have you been convicted of or pled guilty or no contest to a felony or misdemeanor other than a minor traffic related infraction? Do not answer “yes” if your conviction record has been annulled, expunged, sealed, pardoned, erased, restricted, or impounded. If yes, state the nature of the conviction or plea, the date, the court and the jurisdiction, the cause (or other identifying) number, and fully explain. *

Yes
No

If yes, please explain.

Briefly explain why you are interested in this program and what you hope to obtain from this course? *

Please complete the following without the aid of a calculator.

1110 + 995= *

1,854
2,105
1,736
375

7 + 50 = *

35
74
57
60

200-13= *

167
187
134
78

Directions: Read the following paragraphs. Then answer the questions following each paragraph. Circle the one best answer. The fastest-growing segment of the population in the United States is the elderly. Because of the medical advances people are living longer. Certified nurse 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
Elderly
Middle Aged

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

Nurses
Doctors
Certified Nursing Assistants

When you take a person’s temperature, you measure their body heat. The body produces heat by breaking down the food you eat and by exercise. The body loses heat by perspiration and breathing. When the body is working properly, its temperature will be with the normal range. The normal range for an adult is 97.6 °– 99.6 °. Body temperature is measured with a thermometer.

Normal range for an adult temperature is *

97.6° – 99.6°
96.7°– 98.6°
98.6° -- 99°

Comments or Questions

Future Classes

I would like to receive email updates regarding future educational sessions.

Disclaimer *

I agree
I disagree

The Institute of Caring Training Program Application does not discriminate because of age, disabled, race, color, national origin, religion, sex, disability or being a qualified disabled veteran or qualified veteran or the Vietnam era or other category protected by law. I hereby affirm that the information provided on the Training Program Application is true and complete. I understand that any false or misleading representations or omissions made on the Training Program Application may disqualify me from the Training Program. I hereby authorize persons such as schools, my current employer (if applicable) and previous employers and other organizations to provide this facility and its affiliates with requested information regarding my application, and I completely release all such persons of entities from any and all liability related to the providing or 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 the program. I understand if selected I may be removed at any time from The Institute of Caring Training Program for any reason with or without notice/cause.

Electronic Signature *

Date

Share this:

Like this: