CNA PROGRAM APPLICATION, ENROLLMENT AGREEMENT & INFORMATION RELEASE


STUDENT CONTACT INFORMATION

Applying for CNA or PCT ?

CNA Certification #

CNA Expiration Date

First Name
Middle Name
Last Name
Telephone

Mobile Number

Personal Number

Home Address
City State
Zip
Email Address
Password
Mothers Maiden Name
Social Security Number --
Emergency Contact Name
Emergency Contact Phone

EDUCATION

Graduate High School ?

Name of High School

Last Grade Completed

GED Obtained ?

Name of High School

College or Vocational School?

Name of College/Vocational School

Major

Number of Credits


ARREST RECORD

Have you ever been convicted of theft/abuse/neglect of an ederly person or child ?
If Yes, Date
Charge

PERSONAL INFORMATION

Race
Gender
Date of Birth
Height Feet Inches
Eye Color

EMPLOYMENT HISTORY

Company Name
Address
Telephone
Start Date
End Date
Title
Salary Per Hour
Add Company ?

Company Name

Address

Telephone

Start Date

End Date

Previous Title

Previous Salary Per Hour

Add Company ?

Company Name

Address

Telephone

Start Date

End Date

Title

Previous Salary Per Hour


OTHER INFORMATION

How did you learn of The Healthcare Institute?

Radio Station

TV Channel

Social Media

Other
Following graduation, I plan to:
What shift would you like to work?
Would you like to be part of the THI job network ?
Please mark any days of the week that you cannot work Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Which class do you prefer?
Choose Class Start Date

DESCRIPTION AND COST
I understand that the CNA Training Program is a full-time, 3 week day or 5 week evening, 100 hour program that includes classroom & clinical training. The total cost of the program is $1300 may be paid by the student or a sponsoring agency, if applicable. Cost includes:
Program Tuition includes registration fee, TN Nurse Assistant Candidate Handbook, & Liability Insurance: $1050 Book & Workbook: $60 CNA Toolkit (Scrubs, stethoscope, gait belt, blood pressure cuff): $100 State Testing Fee: $90
The tuition is guaranteed for a period of one year from the date below. In addition to tuition, the student will need sneakers or nursing shoes, which may also be purchased by the student or supplied by a sponsoring agency. Students are required to provide a drug screen, background check, and evidence of screening for tuberculosis within the last 12 months at his/her expense. Total cost of supplies may be less than $100.

TRANSFERABILITY OF CREDIT
Previous training in any health care field will not replace any material covered in this program. The CNA Training Program is a private, special purpose program. That purpose is the preparation of students to work as CNAs. This purpose does not include preparing students for further college study. Participation in the training program does not constitute a guarantee that credits will transfer to another institution. Students should be aware that transfer of credit is always the responsibility of the receiving institution. Whether or not credits transfer is solely up to the receiving institution. Any student interested in transferring credit hours should check with the receiving institution directly to determine to what extent, if any, credit hours can be transferred.

PROGRAM DATA
For the program entitled Certified Nurse Aide (CNA), I have been informed that the withdrawal rate is 0%,completion rate is 0%, and in-field placement rate is 0%. Detailed statistical data for this program may be viewed by going to http://state.tn.us/thec and clicking “Authorized Institutions Data” button. No information is available at this time, because THI’s CNA program is a new program.

WITHDRAWAL/TERMINATION/REFUNDS
Date of withdrawal/termination will be the date on the termination notice if terminated, the date the institution receives a written withdrawal notice, or if no written notice is given, the last day of attendance. For tuition paid by student assistance programs, The Healthcare Institute, LLC will adhere to the refund policy prescribed by the sponsor. For a student whose tuition is not paid through a sponsoring agency, the following formula will be used to determine the amount of refund: Withdrawal on/before first day of class, or failure to begin class Full refund minus $100 administrative fee Withdrawal prior to 10% completion 75% refund minus $100 administrative fee Withdrawal between 10%-24% completion 25% refund minus $100 administrative fee Withdrawal at or beyond 25% completion No refund Any student who is unable to complete class because the institution discontinued such class during a period of enrollment for which the student was charged will receive a full refund.

GRIEVANCE
I realize that any grievances not resolved on the institutional level may be forwarded to: Tennessee Higher Education Commission
404 James Robertson Parkway
Nashville, TN 37243-0830
(615) 741-5293

By signing below, I confirm my full-time enrollment in the CNA Training Program of The Healthcare Institute LLC , and agree to comply with all policies of the school, as stated in the Course Catalog. I agree to indemnify and hold harmless The Healthcare Institute, LLC, its employees, agents, sponsors, and externship representatives from any and all actions, causes of action, or claims of any kind or nature during my participation in activities in the classroom, skills lab, clinical experience, externship, or other activities. I give consent for my photograph to be taken and used in promotional materials for the school. I represent that I am in such physical condition as to allow me to participate fully in all activities of the program. I agree to notify the institution of any disability I may have that falls under the American Disability Act and requires reasonable accommodations and/or assistance with evacuation in an emergency. I have reviewed and been given a copy of the CNA Training Program course catalog and a copy of this agreement.

INFORMATION RELEASE
I give permission to The Healthcare Institute, LLC and its representatives to contact previous employers, schools, agencies, and other institutions, in order to obtain information about my background. Further I give permission for The Healthcare Institute, LLC to perform a background check of my arrest record and to perform a drug test and TB skin test.

The Healthcare Institute, LLC has my permission to release my information, including, but not limited to grades, attendance records, background check and drug test to potential employers and to sponsoring agencies or parties. I hold The Healthcare Institute, LLC harmless from any liability associated with the obtaining or the release of information. I certify that all information I have given is true. I understand that providing false information is grounds for termination from this program. I have received an exact signed copy of this agreement.
By selecting Yes you agree with the content of the application Yes No
Enter Name as Signature