CNA Registration Form CNA Registration Form Please fill out this form to register for CNA classes 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Date of birth* MM slash DD slash YYYY Highest Grade Completed**Less than high school graduationHigh School GraduateGEDSome Post H.S., no degree or certificateAssociate DegreeCertificateBachelor Degree or AboveHave 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 What 2022-23 class date are you registering for?*December 28th-February 8th (Wednesday)January 18th to February 8th (Wednesday)January 26th-March 9th (Thursday)February 6th-March 20th (Monday)March 23rd-May 4th (Thursday)April 3rd-May 15th (Monday)May 18th-June 29th (Thursday)May 29th-July 10th (Monday)July 13th-Aug. 24th (Thursday)July 24th-Sept. 11th (Monday)September 7th-Oct. 19th (Thursday)September 25th-November 6th (Monday)November 2nd-Dec. 21st (Thursday)November 20th-Jan. 1st (Monday)dates are subject to changeDay or Evening?*Select One...DayEveningOnly 8 Students per class. First serve first come. Date* MM slash DD slash YYYY *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: CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.