Enroll In Our CNA Program Application Form Full NameStreet Address *CityState/ProvinceZIP / Postal CodePhone NumberEmailGenderFemaleMaleOtherPrefer not to sayDate of BirthCountry of CitizenshipName of High School AttendedCityState/ProvinceYear of Graduation from high schoolPost-secondary Credentials & CertificationsPersonal DataThe following questions Confidential and will be treated as such:1. Disability Status (Select One)NoneYesDisability Affecting EmploymentDevelopmental DisabilityLearning DisabilityPrefer Not to Answer2. Ethnicity (Select one)HispanicNon-HispanicBlack3. Race (Select all that apply)White/CaucasianNon-HispanicAsianHawaiian or Pacific IslandBlack/African AmericanAmerican Indian or Alaskan Native4. Do you have a medical condition which in any way may impairs or limits your ability to be trained as a CNA or perform reasonable skill and safety? If yes, please explain.“Medical Condition” includes physiological, mental or psychological conditions or disorders, such as, but not limited to orthopedic, visual, speech, and hearing impairments, cerebral palsy, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease, diabetes, intellectual disabilities, emotional or mental illness, specific learning disabilities, tuberculosis, drug addiction, and alcoholism.5. Do you currently use chemical substance(s) in any way which may impair or limit your ability to be trained as a CNA or affect your ability to perform reasonable skill and safety? This includes medication.“Currently” means within the past two years. “Chemical substances” include alcohol, drugs, or medications, whether taken legally or illegally. 6. Are you currently engaged in the illegal use of controlled substances?“Currently” means within the past two years. Illegal use of controlled substances is the use of controlled substances (e.g., marijuana, heroin, cocaine) not obtained legally or taken according to the directions of a licensed health care practitioner. 7. Have you been convicted of a misdemeanor or a felony? List the year and describe the event:Georgia State Law prohibits health care facilities from hiring Individuals with murder/felony/attempted murder charges, Cruelty to elderly or children, sexual offenses, Rape, Armed robbery, history of abuse/neglect/exploitation, aggravated battery/assault or violent offenses on their record. Agreement & AuthorizationBy submitting this application, you certify that: All information provided is true and correct to the best of your knowledge You understand that false information may lead to denial or withdrawal from the program You authorize Primrose Health Institute to conduct a background check and random drug screenings during the program By clicking "Submit Application", you agree to these terms.Submit ApplicationSave as DraftPlease do not fill in this field.
