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Three Week Certified Nurse Aide Training Program

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 2012 28th St. S.E. Suites B & C

Grand Rapids, MI  49508

T-(616) 245-2555  F-(616) 245-1253




STUDENT PROGRAM APPLICATION

(Please PRINT LEGIBLY and complete all sections)



First Name:__________________________Middle:_______________Last:________________________


Maiden Name:________________________________Date of Birth:______________________


Address:_________________________________________________________________

City:_____________________________________State:____________Zip:___________

Social Security #:_________________________ DL #:___________________________

Telephone # (Day):________________________Evening:_________________________

Email Address:___________________________________________________________

Class Start Date:________________A.M. / P.M.  Location: Muskegon   or  Grand Rapids

Have you ever been convicted of a Felony or Misdemeanor?   Yes   or   No

If yes, date of conviction:_______________What was the conviction:________________

________________________________________________________________________


EMERGENCY CONTACT


Contact Person: ______________________________Relationship:__________________

Telephone #:____________________________

Alternate Contact:_____________________________Relationship:_________________

Telephone #:____________________________


EDUCATION


High School Attended:______________________________Grade Completed:_________

Graduation Date:___________________ Diploma   or   GED

College:   Yes   or   No         College Attended:__________________________________

Certificate  or  Degree: _____________________________________________________

Explain future educational plans:_____________________________________________

Why did you choose to become a Certified Nursing Assistant?______________________

________________________________________________________________________






MEDICAL INFORMATION


1.  Do you have any allergies to Latex?   Yes   or   No   


2.  Are you pregnant or could you be pregnant?   Yes   or   No  


If you answered yes to the above question, when is your due date:___________________.

If you are pregnant before you start class you will be required to obtain a doctor release 

statement including the following information:  "Student can participate in the Certified

Nurse Aide training program without any medical restrictions and is able to lift 50lbs."

If you are unable to obtain the doctor release you will need to start your class after the 

birth of your child or when you are able to obtain a doctor medical release form with the

above-mentioned information included.  This requirement is in the best interest of you

and your unborn child.   X_______________(initial)


3.  Are you able to lift, pull or push 50lbs without assistance?   Yes   or   No 


4.  Do you have any type of medical relation condition or family life situation that could 

hinder you in a high stress situation?   Yes   or   No  


5.  If yes, please explain your condition________________________________________


________________________________________________________________________


6.  Are you currently under doctor care for the above mentioned condition?  Yes   or  No


Answering yes to the above questions does not mean you will be denied admission; 

however you may be asked to obtain a clearance from your medical care provider to 

assure you are not in any crisis situation and are stable enough to meet the stress demands

of this program.


7.  Do you have any physical limitations that would prevent you from standing on your

feet between 2 to 4 hours at a time?   Yes   or   No


8.  Are you currently taking any medications that could impair your judgment, alter your 

perception or cause dizziness?   Yes   or   No


9.  If you answered yes, please list the medications:_______________________________


_________________________________________________X______________(initial).



















By signing this application you are granting Stepping Stones Educational System, Inc.,

permission to contact your physician if we need to confirm any information you have

given us regarding any medical limitations that could affect your ability to successfully

meet the objectives of our program.  You are also stating that all the information given in 

this application is true and correct.  If you have disclosed or answered any questions

untruthfully you understand it could result in you being immediately dismissed.  All

information you release to us on this application will be kept confidential and only used

for the purposes of confirming information for admission to our program including but

not limited to a Criminal Background History.


____________________________________

Student Printed Name


____________________________________                    __________________________

Student Signature                                                                Date


____________________________________

Program Representative