Semester Applying For: Summer, and Winter Spring (January) fall (September) Program: C.N.A. HHA PERSONAL INFORMATION {please print}Name Last Name First Name MI Sex Male Female Date of Birth/Age Social Security Number Driver License Number/CA ID State Phone NumberHome CellMailing Address Mailing Address Street Name City State / Province / Region ZIP / Postal Code Place of Birth Height Weight Eye color Hair color 1. Have you ever been convicted, of any crime, other than a minor traffic violation Yes No explain2. Do you smoke Cigarettes Yes No 3. How many packs per day? 3. Do you drink alcohol? Yes No on speciat occasions every day more than 2 time s/wk 4. What type of transportation will you rely on to get to school and clinical? own car RTA other No.4 5. Are you a High School Graduate Yes no G.E.D.? Yes no Late Grade Completed No.5 6. What is your religious affiliation? 7. Have you previously held a Certified Nurse's Assistant License? Yes No Date Expired MM slash DD slash YYYY Emergency Contact Name First PhoneCountry of Citizenship Current Status Permanent Resident (registration number) Other (please explain) Occupation Employer Business Address Street Address Hours per week you work How long working at this EDUCATIONAL INFORMATIONPlease list any formal educational programs you have attended and completedCourse/SchooI Date of Attendance MM slash DD slash YYYY Certificate/degree earned Have you ever been academically dismissed from, declare ineligible to attend or incurred disciplinary action at any educational institution? Yes No Have you ever been academically dismissed from, declare ineligible to attend or incurred disciplinary action at any educational institution?STATISTICAL QUESTION IS OPTIONAL. THE ANSWERS WILL BE USED FOR INSTITUTIONAL RESEARCH AND FEDERAL REPORTS ONLYPlease mark on or more of the following cultural backgrounds American Indian or Alaska Native Black or African American Native Hawaiian or other Pacific Islander Asian White Mixed (Black and White) Hispanic/Latino Nonresident alien Race/ethnicity other Please mark on or more of the following cultural backgrounds STATEMENT OF AGREEMENT In compliance with both state and federal law, Inland Christian Academy of Nursing does not illegally discriminate on the basis of any protected category, except to the extent it is necessary to fulfill its religious purpose, mission and vision, so as to be in compliance with the Christian Faith and Message. CERTIFICATION: I certify that, to the best of my knowledge, the information furnished on this application is true and complete. I agree that if admitted, I will abide by the policies, procedures and school rules and regulations as set by Inland Christian Academy of Nursing student handbook.-ff any information is found to be falsified, it may lead to dismissal from the program. If there is a dispute between the educational institution and myself, the Student Handbook outline the appropriate grievance procedure. I understand ICAN regulations prohibiting the use of tobacco, alcoholic beverages, and illegal drugs on campus and personal life as a rote model for the Christ centered educational institution student conduct policies. I understand that falsification, withholding pertinent data, or failure to comply with the nursing schools regulation may result in my dismissal.Student SignaturePrint Name First Date MM slash DD slash YYYY Director of Nurses SignaturePrint Name First Date MM slash DD slash YYYY SUBMIT APPLICATION TO:Inland Christian Academy Of Nursing Application Process 3233 Arlington Ave. #203 Riverside, CA. 92506 inland Christian Academy of Nursing Student Nurse Physical Exam Form Personal Information: Name First DOB Age Weight: Pounds KG. Height: Ft Sex Yes No MEDICAL HISTORYCheck if condition is present and provide comments: Mental illness Cancer Ulcer Impaired Hearing Hypertension Heart Disease Impaired Sight Allergies Neurosis Any Surgical Operations Diabetes Epilepsy Speech Defects Arthritis Venereal Disease Orthopedic Defects Tuberculosis Depression Chemical Dependence Hereditary Disease Asthma/ COPD Comments:PHYSICAL EXAMINATIONEyes TB Test (date & result) E.N.T CBC abnormities Lungs U/A (date and findings) Back/Joints Abdominal heart tones Pulse Rate B/P Any Physical Job Restrictions:Immunization and Childhood Disease: Place a "X"in appropriate box and Numbers with titerVaccine NameInfluenzaChildhood Disease Vaccine Date MM slash DD slash YYYY Titer NumberTetanus, diphtheria, pertussis (Td/Tdap) every 10 yearsVaccine Date MM slash DD slash YYYY Titer NumberMeasles, mumps, rubella (MMR)Childhood Disease Vaccine Date MM slash DD slash YYYY Titer NumberMeningococcal 1 or more dosages for all adult agesChildhood Disease Vaccine Date MM slash DD slash YYYY Titer NumberHepatitis A 2 doses for all agesChildhood Disease Vaccine Date MM slash DD slash YYYY Titer NumberHepatitis B1st date MM slash DD slash YYYY 1st date MM slash DD slash YYYY 1st date MM slash DD slash YYYY Titers for Hepatitis final dosageChildhood Disease Vaccine Date MM slash DD slash YYYY Titer NumberRubella (German Measles)Childhood Disease Vaccine Date MM slash DD slash YYYY Titer NumberPolio VaccineChildhood Disease Vaccine Date MM slash DD slash YYYY Titer NumberCovid 19Childhood Disease Vaccine Date MM slash DD slash YYYY Titer NumberHEALTH CARE PROVIDERS SIGNATURESignature/TitlePrint Lic # Date MM slash DD slash YYYY Health Facility Address Health Facility Address City State Zip Certified Nursing Assistant/Home Health Aide Program Tuition and Fees Programs/ * = included in program total cost Fees/Cost $2392.OO *C.N.A. $1,800 * *H.H.A. $500 Class Uniform (top and pants) Purple Scrubs Clinic Uniform (top and pants) White Scrubs 2- School Uniform Patches (Press on patch to right arm of uniform). I-Purple uniform jacket pen light B/P cuff Stethoscope Student School Badge $ 250.00* 1 Pair of Duty or all White Leather Tennis Shoes $ Self* Purchase CPR Course BLS American Heart Association (no Red Cross) $60.00* Mal Practice Insurance (Nurse Service organization NCO) Selfpurchase Registration Fees $200 Non-refundable* State Certification Examination $120 (American Red Cross) Self-purchase Life Scan $80 Self-Purchase C.N.A, Text book (Nurse Assistant) $67.00 * Certification California ED 2020) $15.00 Shipping * HHA Textbook (Home Health Aid the Complete Guide ED 2022) $36.25 CeN.A. Module $20.00 (self-purchase or download) H.HaA. Module $20.00 (self-purchase or download) * *Physicians Examinations and blood test See your health care provider Program Cost and Payment PlanPayment Plans: 1. Two Payments Plan $1196.00 Course Start Date $ 4th week of course: 1196.00 (Paid in full) 2. Three Payments Plan a. $1000.00 Course Start Date b. $696.00 by the 3rd week c. $696.00 by the 4Th wee Home Health Aid Program: Full Payment: $ 500 Day of course start time or prior Tuition Agreement Signature: This signature indicates that I agree with the financial terms listed in this document and I will follow the payment plan or be subject to program dismissal. Non-payments, students grades will not be released to write state certificate exam until all payments are paid in full.Student SignatureDate MM slash DD slash YYYY School Official Witness SignatureDate MM slash DD slash YYYY CAPTCHA
