OBRA CNA
ADMISSION APPLICATION:

Please print & complete ALL spaces with a pen. Upon completion, please mail to CHES, LLC P.O. Box 215 Hersey, MI 49639 OR turn into your referring agency for evaluation and prerequisite actions. Completion of an application does not ensure admission for agency referred students as you must also qualify for their agency funding.

NAME__________________________________

ADDRESS ________________________________________
              
                 ________________________________________
           
HOME PHONE: _________________________

CELL PHONE: __________________________

EMERGENCY CONTACT: (name and phone)

________________________________________


E-mail: _________________________________

Date of Birth: __________________ (must be 18 OR in an approved career technical center)

EDUCATION: List highest grade completed:

 



WORK EXPERIENCE: List all health care work experience you have had:


 



Have you ever been convicted of a felony or high misdemeanor crime?
YES_______ NO __________

If yes, please list charges.


NOTE: Applicants for the CNA course should be aware of the physical requirements of the job. These include:

· Must be physically capable of lifting 50 pounds,
· Stand on feet for prolonged periods of time,
· Possess a minimum 5th grade reading level,
· Have vision within normal limits (corrected),
· Have hearing within normal limits (uncorrected).

Do you have any limitations that may impact your ability to meet the requirements listed above?

YES_______ NO __________
If yes, please list.
 

DO YOU HAVE A LATEX ALLERGY? YES____ NO _____

 

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REFUND INFORMATION: The tuition and fees paid by the applicant shall be refunded if the applicant is rejected by the school before enrollment. An application fee of not more than $25.00 may be retained by the school if the application is denied. All tuition and fees paid by the applicant shall be refunded if requested within 3 business days after signing a contract with the school. All refunds shall be returned within 30 days. Once the 3 business days have elapsed the following refund policy will apply: Students who do not complete the course, due to medical or personal reasons may be due a reimbursement of part or all of the class cost. The following applies: Dropped before first class: 100% return minus $25.00 processing fee. Dropped before first clinical: 75% return minus $25.00 processing fee. Dropped before second clinical : 50% return minus $25.00 process fee. Dropped after second clinical : No return of costs. The above only applies if a student personally pays tuition costs. If the student tuition is paid by a referring agency, the tuition reimbursement will be made to that agency.