Certified Nursing Assistant Training Program Registration Form

To be eligible for the CNA training course candidates must be at least 17 years of age of older, have a valid government issued ID, a negative TB test/chest x-ray, and be able to pass a criminal background check. Individuals under 18 years of age must provide parent/guardian information and have their consent.

Bring the following documentation for registration

• valid government issued ID such as a driver's license, state ID, or passport
• Original Social Security Card
• Current Immunization Records (TDAP, HEB B, MMR, TB, Varicella, Annual Influenza, Covid Vaccine)
• Negative TB skin Test or chest x-ray within calendar year before beginning clinical rotation

• Physical
• High School Permission form if applicable
• CPR certifications if applicable

Name *

First Name Middle NameLast NameSuffix

Date of Birth*

Date

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Social Security Number*

Driver's License Number*

Emergency Contact*

First NameLast Name

Relationship of Emergency Contact*

Phone Number*

Please enter a valid phone number.

Do you hold a High School Diploma or GED*

yesno

Do you hold a Associate's or Bachelor's Degrees*

yesno

Last School Attended

Graduation Date

Date

If younger than 18yrs of age what grade are you in? High school students must secure permission through their school principal (contact Medpro Healthcare Training LLC for document

Please provide the name of your Parent/Guardian

First NameLast Name

Parent/Guardian Email

example@example.com

Parent/Guardian Phone Number

Please enter a valid phone number.

Parent/Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Have you been convicted of a crime?*

Please be aware that all candidates will have a criminal background check completed

If you answered yes to the previous question, please explain.

Do you have access to Technology?*

ComputerSmart PhoneTabletnone

Do you have any physical or cognitive limitations that may effect your duties as a nursing assistant? If yes, please explain

Please review the options below to select your preferred start date.

We offer the following class options: Hybrid classes- Thur/Sat in-class instruct and Saturday-in class instruct.

Important Note: While we strive to accommodate all requests, class spots are filled on a first-come, first-served basis. Students who complete their enrollment in full will be given priority in securing their spots.

Hybrid course meets:

wk 1-self paced online (approx. 2-3 hours each day)

wk 2- self paced with in-class instruction designated days

wk 3- self paced with in-class instruction designated days

What course are you interested in taking?*

In-class instruction 8:30am-4:30p

Please tell us why you are interested in this program*

Describe a situation where you demonstrated compassion toward a patient or someone in need. What actions did you take, and what difference did it make for them?*

What are your career goals after completing this program?*

How did you hear about our program?

Please Upload a copy of your governmental ID (driver's License, State ID or U.S Passport)*

I attest that all information disclosed is correct. I understand that failure to disclose or falsify information could result in my this result in dismissal from the CNA course. I authorize Medpro Healthcare Training LLC to use pertinent information provided on this form to determine eligibility for enrollment and I acknowledge the required application fee is non- refundable. I understand that a background check will be performed in order to consider each candidate for enrollment. Place your signature below if you consent to a background check.

Signature*

Attach Scan copy negative TB/ Chest Xray

Attach Scan copy of Current Immunizations

Parent/Guardian (driver's License, State ID or U.S Passport)

I attest that all information disclosed is correct. I understand that failure to disclose or falsify information could result in my this result in dismissal from the CNA course. I authorize Medpro Healthcare Training LLC to use pertinent information provided on this form to determine eligibility for enrollment and I acknowledge the required application fee is non- refundable. I understand that a background check will be performed in order to consider each candidate for enrollment. Place your signature below if you consent to a background check.

Parent/Guardian Signature

• Your signature indicates all information is correct and you authrorize Medpro Healthcare Training LLC administration department to perform a criminal background check.

• By enrolling in a course at Medpro Healthcare Training LLC, I acknowledge and agree to the following terms regarding financial responsibility: I understand that I am responsible for paying the full tuition amount associated with the course, including any non-refundable fees such as the application fee, administrative fees, or processing charges, as outlined in the course information provided at the time of enrollment. By signing below or submitting my enrollment electronically, I agree to the terms listed above and accept full financial responsibility for all tuition and fees incurred as part of my course enrollment.

• I understand that after completing this course, I must register for the Headmaster TMU certification exam for which is an additional $175.00 to be paid directly to that entity. I also understand that once I have successfully passed the certification exam, I must pay the state of Michigan $40.00 for the initial certification and $40.00 every two years for the renewal period.

How will you be paying for course*

If sponsored will tuition be paid by Michigan Works or Employer?

When submitting a payment the ID must match the name of card being used. If using someone else’s card, you must upload their ID also in the section where it states "Please Upload a copy of your governmental ID"

My Products

Enrollment Fee (Non Refundable) Product Image

Enrollment Fee (Non Refundable)Applications will not be processed until enrollment fee is complete. Please contact us at 248-230-8455 before making necessary payment to ask any questions.

$100.00 Quantity

Course Tuition (hybrid-virtual) Black Friday Deal Product Image

Course Tuition (hybrid-virtual) Black Friday DealThis class is currently offered at a discounted tuition of $750 with books included. Add only if you would like to pay the full tuition balance upfront. Otherwise, the tuition balance will be invoiced and must be paid prior to starting the course.

$750.00 Quantity

Course Tuition (weekends)This class is currently offered at a discounted tuition of $1200 with books included. Add only if you would like to pay the full tuition balance upfront. Otherwise, the tuition balance will be invoiced and must be paid prior to starting the course.

$1,200.00 Quantity

Total

$0.00

Payment Methods

Credit Card

ACH Bank Transfer

Afterpay