Regional Career & Technical Education (Cte)

REGIONAL CAREER & TECHNICAL EDUCATION (CTE)

CERTIFIED NURSING ASSISTANT (CNA)TRAINING APPLICATION

Application Deadline: November 10, 2014

Dates: Visit with your School Guidance Counselor about Enrollment Times

Name:______

(Last)(First)(Middle)

Home Address:

(Street)(City)(State)(Zip)

Mailing Address if different from above:

(Street or PO Box)(City)(State)(Zip)

Phone: ( ) Email Address:

Birth date: Present Age______Sex: Male Female

Social Security Number:______(Application Confidential)

Name(s) of Parent(s) or Guardian:

Daytime Phone Number: (____)______Evening Phone Number:(____)______

Daytime Phone Number: (____)______Evening Phone Number:(____)______

Name of School Attending: ______

(Street or PO Box)(City)(State)(Zip)

GPA:______Grade you are currently in: 10th 11th 12th Other

What do you plan to do after High School?

_____ Get a job (do not check this if you are just planning to work for the summer)

_____ Go to a 2 Year College (Major______)

_____ Go to a 4 Year College or University (Major______)

_____ Other ______

Race/Ethnicity:

American Indian Hispanic or Latino

Alaska Native Native Hawaiian or Pacific Islander

Asian White

Black or African American Mixed Race

How did you hear about the Certified Nursing Assistant Training?

Friend Teacher or Guidance Counselor

Parent Newspaper

Health Professional Online

Flyer or Poster Other:

This personal statement will help us get to know you better and demonstrate your ability to organize your thoughts and express yourself. Please attach an essay of no more than 200 words addressing both of the following questions:

1)Discuss why you want to attend the CNA Training and your interest in becoming a Certified Nursing Assistant.

2)Describe any community service activities you have been involved in.

To be completed by A SCHOOL REPRESENTATIVE:

I hereby recommend to attend the 2014Regional CTE Certified Nursing Assistant Training/Avera sponosored. If this student is on an IEP and special accommodations are needed, please indicate/explain on a separate sheet of paper.

Printed Name of School RepresentativeSignature Date

To be completed by APPLICANT and PARENT/LEGAL GUARDIAN:

I certify that the information given in this application is true and correct. I have proofread for accuracy and completeness. I realize that applications are accepted only when complete.

Signature of Applicant Date

Photograph and Publicity Release Form

I, ______, give Yankton Rural Area Health Education Center (YRAHEC), Avera Education & Staffing Solutions (AESS), andthe participating school districts* (SCHOOLS) permission to use my name, likeness, image, voice, and/or appearance as such may be embodied in any pictures, photos, video recordings, audiotapes, digital images, and the like, taken or made on behalf of YRAHEC, AESS,and the SCHOOLS activities. I agree that YRAHEC,AESS, and the SCHOOLS have complete ownership of such pictures, etc., including the entire copyright, and may use them for any purpose consistent with YRAHEC, AESS, and SCHOOLS’ missions. These uses include, but are not limited to, illustrations, bulletins, exhibitions, videotapes, reprints, reproductions, publications, advertisements, and any promotional or educational materials in any medium now known or later developed, including the Internet. I acknowledge that I will not receive any compensation for the use of such pictures, etc., and hereby release YRAHEC,AESS, and the SCHOOLS and their agents and assignees from any and all claims which arise out of or are in any way connected with such use. I have read and understood this consent and release.

I give my consentto YRAHEC,AESS, and the SCHOOLSto use my name and likeness.

______

Signaturedate

______

Parent / legal guardian (if age 17 and under)date

Release And Waiver Of Liability

In consideration of allowing me to participate in the certified nurse aide training, I, the undersigned (or parent or legal guardian if a minor), do hereby waive, release, and forever discharge Avera Education and Staffing Solutions,its affiliates, officers, agents, employees, agents and representatives, from any and all liability, including future damages, from injuries or damages of any kind resulting from my participation in the certified nurse aide training. I have voluntarily and knowingly agreed to participate in the certified nurse aide training and do hereby assumeall responsibility for my participation and activities in such training.

______

Signature of ParticipantDate

______

Printed Name of Participant

______

Signature Parent or Legal Guardian if MinorDate

______

Printed Name of Parent or Legal Guardian

______

Signature of WitnessDate

______

Printed Name of Witness

To be completed by PARENT or GUARDIAN:

I give permission for to participate in the Certified Nursing Assistant Training. I certify that she/he is covered by our family health insurance policy. If she/he is injured, I give my permission for a doctor to administer appropriate treatment. I release the involved entities and their employees from all claims resulting from injuries which may be sustained by my daughter/son while attending theCamp.

Signature of Parent or Guardian Date

Applicants will be notified by letter and by their school counselor.

PLEASE NOTE: If selected to attend the Certified Nursing Assistant Training, I will ensure my child will have a current TB skin test and documentation of 2MMR immunizations that will be submitted prior to the start date.

Signature of Parent or Guardian______Date______

Please submit application to: Your School Guidance Counselor

Call 605-655-1400 or email with any questions/concerns.

Collaborators making this training possible:

1