Application Form COURSES FOR WHICH YOU WANT TO ENROLL NAME OF COURSE
START DATE
COURSE FEE
Nurse Aide Class – day class
August 11, 2025
$1,070
Monday, Wednesday, Friday
9:00AM-2:00PM
Personal Care Assistant – day class Registered Medication Aide
LAST NAME
LENGTH OF CLASS AND CLINICAL 140 HOURS
Monday – Friday 9:00AM$300.00 6:00PM – offered every other week each month June 2nd Mon-Friday $750.00 9:00AM-2:00PM ABOUT YOURSELF
40 HOURS
FIRST NAME
DATE OF BIRTH
TITLE (MR./MRS./MS)
68 HOURS
CONTACT INFORMATION HOME PHONE
CELL PHONE
EMAIL ADDRESS HOME ADDRESS
ADDRESS
CITY
STATE
ZIP CODE
PREREQUISITES FOR CLASSES – PLEASE CHECK ALL THAT APPLY
HIGH SCHOOL DIPOLMA OR GED MUST BE ABLE TO READ AND WRITE IN ENGLISH THE FOLLOWING ARE FOR THE RMA CLASS ONLY (please provide a copy of the certificate you check below) SUCCESSSFUL COMPLETION OF A 40-HOUR DIRECT CARE STAFF TRAINING SUCCESSFUL COMPLETION OF A 40-HOUR PERSONAL CARE AIDE TRAINING SUCCESSFUL COMPLETION OF A BOARD OF NURSING APPROVED NURSE AIDE PROGRAM SUCCESSFUL COMPLETION OF ONE CLINICAL COURSE OF A NURSING PROGRAM