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 2024 class date are you registering for?*January 8th-March 4th (Monday)January 25th-March 14th (Thursday)February 14th-April 3rd Wednesday)March 18th-May 6th (Monday)March 28th-May 16th (Thursday)May 20th-July 15th (Monday)May 30th-July 25th (Thursday)July 29th-September 23rd (Monday)August 8th-October 3rd (Thursday)October 7th-December 2nd (Monday)October 17th-December 12th (Thursday)December 16th-February 12th (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.