CNA Registration Form

Please fill out this form to register for CNA classes

Comments
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Class holds 16 students, clinical holds 8 students days and 8 evenings. Once class is filled up you will not be able to register for this class, but you may register for any other date.
Name*
First Last
Email*
Address
Street Address City State ZIP Code
Phone*
Date of birth*
Highest Grade Completed**
Have you ever been convicted of any crime**
- Yes
- No
if 'Yes' please explain
Have you ever had any license, certificate, registration or other privilege to practice a health care profession denied, revoked, suspended or restricted by a state, federal or foreign authority?**
- Yes
- No
if 'Yes' please explain
call 219-671-8187 for dates*
dates are subject to change
Day or Evening?*
Only 8 Students per class. First serve first come.
Date*
*Note that not paying after registration will not secure you a spot in the class. Please proceed to payment from the confirmation page. ALL CLASS PAYMENTS ARE DUE BEFORE CLASS STARTS.
Class Cost
Price:
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Time

: Hours

Minutes

AM/PM
Website
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country