REGISTRATION FORM

Divine CNA Training

1707 S 341st Place, Unit D, Federal Way, WA 98003

253-874-0174

$35.00 registration fee , $550.00 CNA course fee. (Money Order, Cashiers Check, Credit/Debit Card or Cash)

Student Name:

Last: ______________________ First: ______________________ Middle: ___________________

Address:______________________________________________________________

City/State/Zip:__________________/_________/___________ Telephone number:_________________

Date of Birth (MM/DD/YYYY): _______ / ______ / _________SS#______________________________

Race (Check one): Gender (Check one): ______Male ______Female

--- Hispanic: EMAIL:________________________________________________

__ White/Caucasian __ Black/African American

__ American Indian or Alaska Native __ Hawaiian Native or other Pacific Islander

__ Asian __ Multi-racial __ Other:

Disability: __ Yes __ No

Highest Grade Completed:

__ Less than high school graduation

__ High School Graduate Graduation Date ___________

__ GED Date GED Attained: _____________

__ Some Post H.S., no degree or certificate __ Certificate (< 2 years)

__ Associate Degree (Year: ______) __ Bachelor Degree or Above (Year: ______)

Name and Address of Last School Attended: _________________________________________

Personal Data Questions:

*1. Have you ever been convicted of any crime YES___ NO___

If yes, please explain____________________________________________________

* 2. 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 __________________________________

When do you want to start: ________________Circle one? Day / Evening.

Monday – Thursday Class, Clinicals are Monday-Friday, Day and Evening

Saturday – Sunday Class, Clinicals are Saturday and Sunday (2 consecutive week ends) Day and Evening

(Evening clinicals are dependant on enrollment)

Applicant Signature: ____________________________________ Today Date _____________

Contact Person in case of Emergency

Name_____________________________________Relationship to you:___________________________

Phone #_________________________________Secondary Phone #______________________________

I understand that there will be a $75.00 fee for any returned personal check by me due to insufficient funds.

HOW DID YOU HEAR ABOUT US: Referral (who referred you)__________________________________________

Facebook____ Newspaper___ Craigslist___ Other____________________________________________________