25820 Orchard Lake Rd.
Farmington Hills, MI 48336
Last Name: First Name: Middle:
Home address: City: State: Zip:
Daytime phone: Evening phone:
Have you graduated from High School? Yes No
Have you passed the GED?Yes No N/A
Are you at least 16 years old? Yes No
Are you currently a: Sophomore Junior Senior in High School N/A
High School student must secure permission through their school principal (see form below)
Have you ever been convicted of a felony? Yes No
If yes, please list:
Can you commit to 14 days of class? Yes NoAttendance in mandatory!!
If the session is full, do you want to be put on a waiting list? Yes No
Emergency Contact InformationName: Relationship Address: Phone:
CNA supports students with disabilities.Are you an applicant with a documented disability? Yes NoIf yes, please explain:
Is English your first language? Yes NoIf not, what is your first language?
Why do you want to attend the CNA course?
What personal qualities do you think a successful CNA should have?
Are you thinking of making healthcare a career? Yes NoIf yes, what area of healthcare are you considering?
TB skin tests will be administered on the 5th class. Positive tests require chest x-rays.Students that have had a TB/PPD test within the last 12 months, may bring the results into the school.
I certify that all the answers given in this application are accurate to the best of my knowledge.I understand that failure to disclose or falsifying information could result in my dismissal from the CNA course.
Parent signature if under 18 years of age: Date:
Print these forms and submit them to the Academy at the address below:High School Permission form (if applicable)Disclosure and Authorization form (required)
Basic Life Support Classes
First Aid/CPR Classes