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Three Week Certified Nurse Aide Training Program

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STEPPING STONES EDUCATIONAL SYSTEM, Inc.

2012 28th Street Suites B & C

Grand Rapids, MI. 49508

616-245-1255

Fax: 616-245-1253

 

STUDENT PROGRAM APPLICATION

(PRINT LEGIBLY and complete all sections)

 

IDENTIFICATION:

 

 

First Name: ___________________Middle: _______________Last: ____________________________

Maiden Name: _______________________________________Date of Birth: ____________________

Address: _____________________________________ City:  _____________State:____ Zip: ______

Social Security #____________________________DL#______________________________________

Telephone # (Day): _______________________ (Evening): __________________________________

Email Address: ______________________________________ Today’s Date: ___________________

Class Start Date: ____________A.M/P.M   Class 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: _____________________________________ Telephone #: ______________________

Relationship:  ___________________________________________________________________________

Alternate Contact: _______________________________ Telephone#: _________________________

EDUCATION:

High School Attended: _________________________________Grade Completed: ______________

Graduation Date: _________________Diploma    or    GED (circle One)

College:  Yes  or  No (circle one)   College Attended: ______________________________________

Certificate  or  Degree (circle one): _______________________________________________________

Explain future educational Plans: _______________________________________________________

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

How did you hear about Stepping Stones? _______________________________________________