1
Student Application
CERTIFIED NURSING
ASSISTANT PROGRAM
Urbana Adult Education
211 N. Race St.
Urbana, IL 61801
Phone: (217) 384-3530
Fax: (217) 337-4987
www.urbanaadulteducation.org
CNA Class
8 weeks
Table of Contents
Parking for the Urbana Adult Education Center ... Page 3 Criteria for Selection & Age Requirement ... Page 4 Enrollment Process, Documents Needed, Immunizations & Call Back Dates ... Page 5-6 Drug Screen, Non-Refundable Fees & Included in Fee ... Page 7 Attire, Class Information & Clinical Information ... Page 8 Disqualifying Convictions ... Page 9 How to Apply for a Conviction Waiver ... Page 10 Restriction on Vocational Hours, Class Duplication & Mandatory Class Hours ... Page 11 Application for CNA Class ... Pages 12-14 Parking Information...Page 15 WIOA Scholarship Program Information & Application ... Pages 16-20 Fee Waiver Guidelines & Fee Waiver Application ... Pages 21-23
Helpful Hint: Resume and professional reference letters on
letterhead will improve your chances to be selected.
Take a look at the website for the sample CNA Competency Exam.
www.nurseaidetesting.com.
Choose “Sample Test”
When turning in your CNA application please park in the following designated area
explained below (STUDENT PARKING LOT). Expect to be at UAEC 2-3 hours.
All students accepted in the Urbana Adult Education Program
must ALSO meet requirements set forth by the Illinois Department
of Public Health. Candidates are selected by the Evaluation
committee of the Urbana Adult Education Center.
Criteria for selection includes, but is not limited to:
ü
successful work experience
ü
volunteer activities
ü
education and training
ü
accountability
ü
oral and written communication skills
ü
positive interpersonal skills
ü
strong work ethic
ü
Reading and Math test scores
If you are currently on probation or parole (for any
conviction), you are not eligible for the CNA class at this
time.
Due to Department of Public Health requirements, clinical
site regulations, and OSHA Regulations, all potential CNA
students must be at least 18 years of age by the
first day of clinical.
This is approximately
6 weeks after the start of program.
CNA Enrollment Process
1. Fill out application entirely.2. Return completed application and ALL supporting documents to Urbana Adult Ed on one of the days and times listed below. Late applications will not be accepted.
3. Complete a math and reading test (calculator provided) when you turn in your application to Urbana Adult Ed. The duration of the test process is usually 2-3 hours. No visitors or children allowed during testing. Please arrive on time. Selection for interviews will be partially based on test results.
4. If selected for an interview, must attend an interview session on January 6th, 2016. Interviews are held in the morning (specific times will be provided as needed) and the average duration is 2 hours.
Thursday, December 10
th, 2015
at 11:00am
Friday, December11
th, 2015
at 9:30 am
Friday, December 11
th, 2015
at 1:30 pm
Please bring the following information with you on this date: 1. Completed application packet.
2. $7.00 application fee (non-refundable). Cash only. $50 and $100 bills will not be accepted.
3. You must provide an official transcript:
➜ An official high school transcript with graduation date, or your passing GED scores. (If you are an “APL Graduate” of Urbana Adult Education, you are not required to bring a high school transcript.)
➜ If you have attended college, please provide us with an official college transcript, along with your high school transcript or GED scores.
➜ If you have a college degree, please provide us with an official college transcript. No high school transcript or GED scores necessary.
4. Valid state-issued Driver’s License or valid state-issued photo ID. Expired IDs are NOT VALID. If the address on the ID is not current, please bring proof of your current address, such as a utility bill or lease.
5. Illinois Department of Human Services Medical Card if you receive one. (This is the free medical care from the state, not your personal insurance card.)
6. If you served in the armed forces, please bring your discharge papers.
7. If applicable, please bring conviction waiver letter from Illinois Department of Public Health.
8. Proof of immunizations from your physician’s office. Shot records may also be available from the public school which you attended.
See next page for list of immunizations needed.
Please return your completed application to Urbana Adult Ed on one of the following dates and times. Note that you will also take the tests at this time and must expect to be here at least 2 hours.
You must bring original documents. Photocopies are not accepted.
Please bring proof of the following immunizations:
• MMR (measles, mumps, rubella). Proof of immunity by titer* or two doses of MMR
separated by one or more months and given on or after the first birthday eliminate the need for rubella, rubeola and mumps vaccination.
• Varicella (Chicken pox). Proof of immunity by titer* or record of two live vaccinations.
Documentation of having the disease IS NOT sufficient.
• Rubeola (Red Measles). Immunization (see MMR, above) or positive Rubeola Screen or
titer*. Persons born prior to 1957 are considered to be immune.
• Influenza Immunization Vaccination for the current season. Required of all students who
are on-site between November 1 and April 30 of each year.
*Please Note: You may want to wait until you find out if you are accepted into the program before you have titers administered.
Important Dates to Remember
(We recommend that you keep these dates in mind when scheduling other meetings/appointments)
On Friday, December 18th, 2015between 9:00 am-1:00 pm, prospective CNA students will call to see if they have been selected to be interviewed. Those selected will set up an appointment for an interview.
On Wednesday, January 6th, 2016 the selected potential students meet with a member of the CNA Evaluation Team for an interview. This interview process will take about 2 hours and it is in the morning. Do not bring children or visitors with you. It is important to arrive on time.
Interviewed students will call back on Friday, January 8th, 2016 between 9:00 am - 12:30 pm to see if they were selected for the class.
On Thursday, January 14th, 2016 the selected Certified Nursing Assistant Students have mandatory
fingerprinting between 10:30 am and 1:00 pm, for those who are not already on the State Health Care Worker Registry. Students will need to bring a valid driver’s license or valid state photo ID. You are required to bring the first installment of $275.00 and proof that the TB Quantiferon Blood Test was administered. Information regarding fingerprinting will be given at orientation. For those who were selected for the class, you will begin onTuesday, January 19th, 2016 at 8:30 am, Carle Conference West B. You are only required to wear scrubs for the labs and the clinical portion of the class. Please bring pen and paper to the first class.
If immunizations are incomplete, you will have until
the end of the first week of class to produce test results
or you will be dropped from the class.
No exceptions!
Drug Screening
Our Clinical Sites are now requiring a 10-panel drug test. The drug test must be administered AFTER the mid-term is passed.
A drug test is a technical analysis of a biological specimen to determine the presence or absence of specified parent drugs or their metabolites.
A "10-panel rapid" tests for the following:
• Amphetamines (including Methamphetamine) • Cocaine
• Barbiturates • Methadone
• Benzodiazepines • Methaqualone
• Buprenorphine • Propoxyphene
• Cannabinoids (THC)
• Opioids (Codeine, Morphine, Heroin, Oxycodone, Hydrocodone, etc.) • Phencyclidine (PCP)
• Synthetic cannabinoids (K2, Spice) • Tricyclic antidepressants
Non-refundable fees
• $7.00 student application fee. (cash only)
• After selection and prior to admission to the class, the fee of $275.00 (1st installment— non-refundable) is required or a fee of $550.00 (full amount) is due at
Fingerprint/Background check on Thursday, January 14th, 2016.
(Credit or debit)
(Checks/Money Orders payable to Urbana Adult Education)
• You will have until Thursday, January 28th, 2016 to make the 2nd installment of $275.00.
CNA students will be required to come to Urbana Adult Education to make the
payment. If we do not receive the 2nd installment by January 28th, you may be at risk of being dropped from the class.
Included in fee
• A TB Quantiferon Blood Test must be administered before Fingerprint Day. You will be required to bring proof that the test was administered. Quantiferon Blood tests performed within one year prior to the clinical portion of the class are acceptable.
Class Information
• Class hours: Monday through Friday, 8:30 am - 12: 30 pm • Class held at: Carle Foundation Hospital, Conference West B • Instructors: Ms. Karen Kaplan, R.N., BSN, CNA Coordinator
Ms. Nancy Roth, R.N., BSN Ms. Suzanne Burklund, R.N. Ms. Pauline Clements, R.N. Ms. Charlene Stevens R.N.
Beginning in the Fall of 2014, the Urbana Adult Education CNA Program is partnering with Carle Foundation Hospital. Highlights are: state-of-the art facility, upgraded technology, new textbooks, and the versatility of working in a hospital and long-term care facility. The partnership allows 25% of each CNA class an opportunity to become a Carle employee. The CNA students that exhibit an outstanding character which shows compassion, caring, and a strong work ethic will be interviewed for a Health Care Tech position at Carle.
Clinical Information
The Clinical portion of the class will be during the last 11 days of class. Clinical locations will be discussed in class. Locations include: Carle Foundation Hospital in Urbana, Country Health Care &
Rehab in Gifford, and Clark-Lindsey Village in Urbana.
Transportation is not provided. Transportation arrangements are the responsibility of the student.
Please note: Clinical hours are Monday through Friday, 8:15am-12: 45 pm.
Labs/Clinical Attire
(The cost of scrubs is not included in the class fee)
For all classroom Labs and the Clinical portion of the CNA Program, you will need: scrubs, white shoes, and a watch with a second hand.
Scrub colors are: Tops: “Wine” or “Black” Pants: “Black” only
Please read the following information on Criminal Convictions.
The Health Care Worker Background Check Act, an Illinois state law, prevents many health care employers from hiring an individual who has certain criminal convictions as a direct care worker and, in long-term care facilities, from being hired as a worker who has or may have access to residents, their living quarters or their financial, medical or personal records (access worker). A conviction waiver does not change your criminal record but it does allow an employer to hire you as a direct care worker or an access worker in long-term care.
Crimes that disqualify you from working as a CNA (this means that you cannot work as a CNA with these convictions.) This list (subject to change) includes both misdemeanors and felonies:
ü Battery, Domestic Battery, Aggravated Battery, Battery of an Unborn Child ü Assault, Aggravated Assault
ü Forgery
ü Receiving a Credit/Debit Card with Intent to Use, Sell, Transfer, Receiving Stolen Debit/Credit Card, Selling a stolen Debit/Credit Card, Using a stolen Debit/Credit Card
ü Fraudulent Use of Electronic Transmission ü Identity Theft, Aggravated Identity Theft ü Theft, Retail Theft, Theft of Mislaid Property ü Robbery, Armed Robbery, Aggravated Robbery ü Burglary, Residential Burglary
ü Armed Violence
ü Criminal Trespass to a Residence
ü Financial Exploitation of an Elderly or Disabled Person ü Murder, Homicide, Manslaughter
ü Kidnaping, Child Abduction, Aiding or Abetting Child Abduction ü Unlawful Restraint, Aggravated Unlawful Restraint, Forcible Detention ü Indecent Solicitation of a Child, Sexual Exploitation of a Child
ü Tampering with food, drugs, or cosmetics ü Aggravated Stalking
ü Home Invasion
ü Sexual Assault, Sexual abuse
ü Endangering the Life/Health of a Child, Cruelty to a Child, Permitting Sexual Abuse of a Child ü Abuse or Gross Neglect of a Long-Term Care Facility Resident
ü Criminal Neglect of an Elderly Person ü Ritual Mutilation, Ritual Abuse of a Child
ü Vehicular Hijacking, Aggravated Vehicular Hijacking ü Arson, Aggravated Arson, or Residential Arson
ü Unlawful use of a Weapon, Unlawful use or Possession of Weapons by a Felon, Aggravated Discharge of a Weapon. Reckless Discharge of a Weapon, Aggravated Unlawful Use of a Weapon, Unlawful Discharge of a Weapon, Unlawful Sale of a Weapon
ü Manufacture, Delivery, Possession, Trafficking of Controlled Substances or Look-alike Substance
ü Manufacture, Delivery, Possession with Intent to Delivery or Manufacture Cannabis, Cannabis Trafficking, Delivery of Cannabis on School Grounds, Delivery to Cannabis to Persons under 18
ü Distribution, Advertisement, Possession , Intent to Manufacture or Distribute Look-alike Substance ü Criminal Drug Conspiracy, Calculated Drug Conspiracy
ü Practice of Nursing without a license
ü Delivering a Controlled, Counterfeit or Look-alike Substance to a Person under 18, Engaging or Employing a Person under 18 to deliver a Controlled, Counterfeit or Look-alike Substance, Violations under the
Methamphetamine Control Act
Please check the website at http://www.idph.state.il.us/nar for a full listing of
disqualifying offenses and a conviction waiver application. Scroll to the bottom of the page and print the PDF for both the Waiver Application and Waiver Application-Facts.
If you have questions regarding a conviction or the conviction waiver
process, please call the Illinois Department of Public Health at 217-785-5133
If you have a conviction that requires a waiver, you must have the letter from
Illinois Department of Public Health that states you were given a conviction
waiver, in hand,
before you can go any further in the application process.
Please see the steps below to apply for a conviction waiver.
To apply for a waiver, follow these steps:
Step 1: To request a conviction waiver application or to ask if you need a conviction waiver, please call the Illinois Department of Public Health at 217-785-5133. It can be printed from www.idph.state.il.us/nar/home.htm.
Step 2: Mail the conviction waiver application to the Department of Public Health. Step 3: After the Department receives your conviction waiver application, you will be sent
instructions for having your fingerprints collected. You must complete a conviction waiver application and have a fingerprint criminal history records check requested by the Department through a contracted livescan vendor. No other background check will be accepted.
Step 4: In six to eight weeks you will receive a letter from Illinois Department of Public Health. Step 5:
When you receive the letter, and the conviction waiver has been
granted, only then can you apply for the CNA class.
If you are unsure whether an arrest or charge became a
conviction, contact the circuit clerk of the county
in which you were arrested.
You may have been convicted or pled guilty and not sent to jail.
An individual may be fined, given probation or conditional
discharge and it is still considered a conviction.
Conviction Waiver Information
A conviction waiver is in effect until you are convicted of another disqualifying offense, which causes the conviction waiver to be automatically revoked. Health care employers must check the Health Care Worker Registry (http://www.idph.state.il.us/nar) to see if you have met training requirements, have any administrative findings and to determine if you have disqualifying offenses or a waiver.. The information on the registry is the only means a health care employer may use to verify that the worker is eligible for employment. If you have any questions, please call the Illinois Department of Public Health at
Restriction on Vocational Hours/Previous Attendance
The Illinois Community College Board has a restriction on the number of vocational training hours per student. Vocational education classes include Computer Skills, Office Careers, and Certified Nursing Assistant. Urbana Adult Education can provide no more than 180 enrolled hours in vocational education classes over the lifetime of a student’s enrollment.
If you have attended the Computer Skills, Office Careers, or Certified Nursing Assistant class previously, and you have used any or all of the 180 vocational hours allowed, the fee waiver does not apply-you must be a fee-based student and will be required to submit the full fee of $550.00. If you have questions, please contact us at 217-384-3530.
Mandatory Class Hours
The Illinois Department of Public Health regulates this
course and your attendance will be closely monitored.
There are no “excused” absences -
absent is absent
.
Tardies are also monitored. Specific information
regarding attendance will be given at a later time.
Please fill out all forms completely. Please print clearly.
Incomplete and illegible applications will not be considered.
Bring Original Documents. Photocopies will not be accepted.
APPLICATION FOR CNA CLASS
Please fill out the following form. This information is required in order to perform your fingerprinting. Please fill in all the blanks. Please include all names used (maiden name, married name, legally changed names, etc).
Social Security Number:_____________________________Date of birth:__________________Age:________ First Name: __________________________________________________________________________________ Middle (full middle name, not initial): ________________________________________________________________
Last: ________________________________________________________________________________________ Other names used (including Maiden):___________________________________________________________ Sex: ☐ Male ☐ Female Marital Status: ☐ Single ☐ Married ☐ Divorced ☐ Widowed Email address: ______________________________________________________________________________ Are you Hispanic or Latino? ☐ yes ☐ no
Are you from more than one ethnic group? Please check all that apply.
☐ American Indian or Alaskan Native ☐ Asian ☐ Black/African American
☐ Native Hawaiian/Pacific Islander ☐ White Primary Racial/Ethnic Group: Please select only one.
☐ American Indian or Alaskan Native ☐ Asian ☐ Black/African American
☐ Native Hawaiian/Pacific Islander ☐ White ☐ Hispanic/Latino
Is English your first language? ☐yes ☐no Native Language?___________________________________ Mailing address: ____________________________________________________________________________
City, State, Zip: _________________________________________County______________________________ Physical address (if different from mailing):______________________________________________________ City, State, Zip____________________________________________County____________________________ Telephone: (home)____________________ (work) ______________________(cell)______________________ Other states where you have lived: ______________________________________________________________ Height: ____________feet _____________inches (no half inches)
Eye color: _____________________ Hair color: ______________________ Weight: ___________________ U.S. Citizen☐yes ☐no, If no, country of citizenship______________________________________________ Place of birth: State_____________________ If not U.S., country___________________________________
Name of Employer (most recent): City & State: Dates worked: Job Title: Reason For Leaving: Name of Employer (most recent): City & State: Dates worked: Job Title: Reason For Leaving: Name of Employer (most recent): City & State: Dates worked: Job Title: Reason For Leaving:
Highest level of school completion:(Please check only one)
☐ High School Diploma ☐ Some College, No Degree
☐ GED ☐ College Degree
School Type:
☐ USA Based School
☐ Non-USA Based School
If not currently attending school, what is the name of the last school that you attended?
____________________________________________________________Date you left: ______________________ Have you ever tested, enrolled, or attended Urbana Adult Education, Even Start, or Storefront before?
☐ yes ☐ no If yes, when? _______________________________________________________________________ Are you currently enrolled in another educational institution? ☐ yes ☐ no
If yes, where? __________________________________________________________________________________ Expected date of graduation: ___________________Certificate expected to receive: __________________________
Total number of minor dependents: ______ Total number of other dependents: ______
Household/Employment
Total household income $________________
☐ weekly ☐monthly ☐yearly
Are you currently employed? ☐yes ☐no If yes: ☐full time ☐part time Total number hours worked per week: __ Where do you work? ______________________________________________________________________
What is your occupation? ____________________________________________________________________ Your Employment History-Begin with most recent
Do you receive a medical card from the state? ☐ yes ☐ no
Please answer the following:
Are you in a program for the homeless? ☐ yes ☐ no Are you low income? ☐ yes ☐ no
Are you on probation? ☐ yes ☐ no Are you on parole? ☐ yes ☐ no
Are you a Veteran? ☐ yes ☐ no Are you a Dislocated Worker? ☐ yes ☐ no Are you a Single Parent? ☐ yes ☐ no Are you a Displaced Homemaker? ☐ yes ☐ no
How did you hear about our CNA program? Please check only one.
☐ Adult Education Instructor
☐ Other Instructor/Counselor/Advisor
☐ Employer
☐ Community Organization
☐ Career Center/WIOA Office
☐ TV, Radio, Newspaper, Internet
☐ Flyer or Poster
☐ Friend/Relative
☐ Other: __________________________ At a job, have you ever been found to be guilty of abuse, neglect, or theft? If yes, explain.
___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Have you ever been convicted of, or pled guilty to a criminal offense other than a minor traffic violation? If yes, explain. Include the city, state, and county where it occurred.
____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ___________________________________________________________________________________________
In case of an emergency, which hospital would you prefer?
☐Carle Hospital ☐Presence Covenant Medical Center ☐Other______________________________________ List all medications for emergency reasons.
___________________________________________________________________________________________ ___________________________________________________________________________________________ Also, list emotional or physical conditions for emergency reasons:
___________________________________________________________________________________________ ___________________________________________________________________________________________ Emergency Contact Information:
Name_____________________________________________________________________________________ Home phone___________________________________ Cell phone ___________________________________ Relationship to you ________________________________________________________________________
I certify that this information is true.
Printed name: ____________________________________________________________________________ Signature: ________________________________________________________Date: ___________________
If you plan on driving to class, please provide the following information
(needed for parking permits).
Urbana Adult Education and Carle Hospital
CNA Course
Automobile Information
Please fill in all the blanks.
Please Print
Last Name: _____________________ First Name: ___________________
Car #1:
Make: _________________ Model: _________________ Year: ________
Ex: Buick, Chevy, Chrysler, Ford, Honda Ex.: Enclave, Caviler, 3000, Civic
Color: ___________________ License Plate #: ______________________
Car #2:
Make: _________________ Model: _________________ Year: ________
Ex: Buick, Chevy, Chrysler, Ford, Honda Ex.: Enclave, Caviler, 3000, Civic
Color: ___________________ License Plate #: ______________________
If you are NOT applying for a fee waiver or
for the WIOA Scholarship Program,
you are finished.
Stop here!
__________________________________________________________________
If you are between the ages of 18-24,
You may be eligible to apply for the
WIOA Scholarship Program.
If you are 25yrs or older you may be
eligible for the Fee Waiver.
Please continue to the next pages for all the
details regarding the WIOA Scholarship &
Through the WIOA (Workforce Innovation and Opportunity Act) Program, Urbana Adult Education has a Scholarship Program that will pay most associated costs for the CNA student to earn his/her CNA license (e.g., costs for TB Quantiferon test, background/fingerprinting check, scrubs, state CNA exam, etc.). In addition, it provides financial incentives for the student to attend the classes, and it would even follow the student for at least one year after CNA graduation and assist with costs to go on to post-secondary education.
In order to be eligible for this WIOA Scholarship, the student must
:
1) Be between 18-24 years old 2) Live in Champaign County
3) Score at a 9th grade level or higher on a Standardized Reading & Math exam (which you will take when you turn in your CNA application)
4) Upon completion of the CNA program, student must go
directly
into the workforce in the health/medical field, or directly on to post-secondary education.5) Show financial need/low income (must meet one of the following requirements) -Receive SNAP Benefits from DHS (LINK card/food stamps) or
-Have a total household income that falls under the categories below
As part of the requirements of the WIOA Scholarship Program, the student must
:
1) Attend a 2-hour Intake Session at the Illinois WorkNet Center (1307 N. Mattis Ave, Champaign) 1-2 weeks before CNA class begins.
2) Attend all WIOA Scholarship meetings at Urbana Adult Ed. Student is also required to attend all tutoring sessions until state exam is passed. Tutoring sessions are usually from 1pm-2:30 pm, 2 to 3 times a month. 3) Remain in good standing in the Urbana Adult Education CNA program
4)Complete and turn in weekly time sheets to the WIOA Scholarship Liaison at Urbana Adult Ed
5) Student must commit to stay in contact (on a monthly basis) with the WIOA Liaison from Urbana Adult Ed for at least 1 year after successfully completing the CNA class.
If you are interested in being considered for the WIOA Scholarship Program:
Please complete in its entirety the following Preliminary WIOA Scholarship Program Application form. It must be turned in with your CNA application. All supporting documents must also be turned in at this time. Late applications or late documents will not be accepted.
Size of family Unit Total Household Yearly Income or less
(Before taxes)
1 $11,770
2 $15,930
3 $20,988
4 $25,910
5 $30,574
6 $35,733
WIOA Scholarship for
Potential CNA Students
Please Include the following supporting documents to complete your
WIOA Scholarship Program Application
(please bring originals, photo copies will not be accepted)
(Keep in mind: some documents required for the WIOA Scholarship Program, you might have already included in your CNA application. If that is the case; WE will use those documents for your WIOA application. You do not need to provide additional copies of those documents)
o Proof of US citizenship
(Birth certificate
OR
passport)o Selective Service Registration (males 18 or older) o Proof of current Address:
-Recent Post Marked Mail (envelope addressed to you, showing current address with post mark) -
OR
Illinois
Department of Human Services Medical Card if you receive one. (This is the free medical care from the state, not your personal insurance card.)o Social Security Card (actual card) o Valid State ID
o Verification of Disability (if applicable) o Proof of Household
-Medical card from DHS/government listing family members
OR
copy of LeaseOR
Birth Certificates of all your children
o Proof of Family Income
**If you receive Food Stamps/LINK Card make sure you have checked off the box at the bottom of the first page of the WIOA application form stating you receive Food Stamps. No additional documents need to be turned in for this section.
**If you DO NOT receive Food Stamps/LINK Card you need to turn in Original Paycheck stubs for the
LAST 6 MONTHS for yourself and each additional household member
.
(Paycheck stubs must date back to the beginning of June) o High School Diploma or High School Transcripts
When you call back on Friday, December 18th, 2015 to find out if you have been selected for an interview, you will also find out if you qualify for the WIOA Scholarship Program.
Please note: Only for those students 25 years of age or older.
Please bring following items when you turn in your CNA application. Bring
originals, photo copies will not be accepted.
•
Paycheck stubs for the
last three months for all members of the household
•
Proof of occupancy with current address (such as: power bill, phone bill, or
cable bill with current address)
•
Social Security Benefits Verification Letter (if applicable)
•
Child Support Award Letter (if applicable)
•
Birth Certificate
•
Social Security Cards
for all members of the household
•
State Photo ID (unexpired)
Step 1: Please verify that you meet income guidelines.
Size of family Yearly
Income
You meet the income Guideline Requirements. If there is only one person in your household and you make less than 13,221
It there are two persons in your household and you make less than 21,671 It there are three persons in your household and you make less than 29,745 It there are four persons in your household and you make less than 36,720 It there are five persons in your household and you make less than 43,331 It there are six persons in your household and you make less than 50,684 It there are seven persons in your household and you make less than 58,037 It there are eight persons in your household and you make less than 65,390 It there are nine persons in your household and you make less than 72,743 It there are ten persons in your household and you make less than 80,096
Step 2: Please fill out all information.
Urbana Adult Education Center
Fee Waiver Application
Step 3: Please fill out Household Income information for all persons in the household.
Total Household Gross Income (before deductions) and how often it is received, for example:
$100/month $100/week $100/twice month
List all household members Earnings from
work child support, Welfare, Alimony Pensions, Retirement, Social Security Workers’ Comp., Unemployment, SSI 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Please total each column Monthly Total Monthly Total Monthly Total Monthly Total
List all household members
First, Middle, Last Name
If child is attending school
what grade & school
SNAP or TANF Case ID number
1. Grade School 2. Grade School 3. Grade School 4. Grade School 5. Grade School 6. Grade School 7. Grade School 8. Grade School 9. Grade School 10. Grade School
Step4: Verify that all information is correct and sign.
I certify all information on this fee waiver
application is true and all income is reported. I
understand if I purposely give false information, this is
grounds for dismissal from the program.
Date ________________________________________________________________________
Printed name of applicant_______________________________________________________
Signature of applicant__________________________________________________________
In compliance with Section 511of Public Law 101-166 (the Stevens Amendment), approximately 29.8% or $331,511 of federal funding supports this program. Reasonable accommodations for students with disabilities are available upon request.
