ENROLLMENT APPLICATION

ENROLLMENT APPLICATION

Nurse Aide Program

Last Name: _______________________________________ First Name ____________ MI: ___

Address: ______________________________________________________________________

City:______________________________ State: _____________ Zip: _____________________

Phone: ___________________________ Emergency Contact ____________________________

Are you 18 or older [ ] yes [ ] No Social Security Number: ________________________

Gee’s Career Training

Institute

EDUCATION

School (high School College) How many Years

Degree/ Diploma Major

Other Trainings Certificate Earned Date

REFERENCES

Please provide names of three people you have known for at least one year (Must be non-relatives)

Name Day Phone # Relationship Year known

I hereby, authorize the release of any information regarding current/past employment and education to Gee’s Career Training Institute. I certify that none of the information was falsified.

Gee’s Career Training

Institute

1822 Featherstone Rd Woodbridge VA 22191

Phone: (703) 910-7239 Fax: (703)910-7238

CANCELLATION AND REFUNDS

1. Student applicants who cancel before the first day of class will be charge $150.00 refundable fee to cover the cost of enrollment processing.

2. Student applicants that are enrolled in a class who cancel after attending the first and second day of class will be entitled to 50% of the tuition.

3. Student who withdraws or is terminated after three (3) classroom sessions may not receive any refunds.

Applicant Printed Signature: _______________________________ Date: ________________

Applicant Signature: ___________________________________________________________

Gee’s Career Training Institute Representative: _____________________________________

Gee’s Career Training

Institute

1822 Featherstone Rd Woodbridge VA 22191

Phone: (703) 910-7239 Fax: (703)910-7238

CRIMINAL DISCLOSURE AND AGREEMENT

I, ______________________________ understand and as I have been advised by Gee’s Career Training Institute that the law prohibit healthcare agencies from hiring any one convicted of crimes unless as proved in the case of misdemeanor crimes. “Misdemeanor crime not involving abuse or neglect or moral turpitude may be hired provided five years have lapsed since the conviction.” I am of sound mind and good judgment while making this decision to educate my self about the healthcare profession by taking the Nurse Aide Program.

I release Gee’s Career Training Institute of any and all liabilities. I agree and promise Gee’s Career Training Institute that I will not seek employment in the healthcare industry while this misdemeanor is still pending on criminal records.

Signature: ________________________________________________ Date: _______________

Gee’s Career Training Institute Representative: _______________________________________

Gee’s Career Training

Institute

If you have nay problem while training at GCTI, please follow the process as outline below: first discuss the issue with your instructor. The instructor will make every effort to resolve the issue, however, if you are not completely satisfied with the result, you should schedule an appointment with the school Administrator, Gifty Kotey R.N., she will make every effort to resolve your problem.

She will also document every effort made to resolve the issue or remedy the situation. If the problem cannot be resolved by the school administrator, you can then contact the Department of Education, P.O. Box 2120, Richmond VA 23216-2120.

Graduation

Upon successful completion, of the program, you will receive a certificate form GCTI. Your certification meets the Department of Health approved standard for Nurse Aide.

Absences and Tardiness

You are responsible for notifying the instructor in advance about any absence or tardiness from class. Any un-excused absence or tardiness may be ground for termination or you may be assessed additional fee for a private tutoring to meet the program requirements.

Termination or Dismissal Policy

GCTI may dismiss a student for any of the following reason:

1. Frequent tardiness or absence due to lack of interest for the program. 2. Failure to maintain academic standard

3. Disorderly conduct either verbally or physically 4. Alcoholism or drug abuse

5. Sexual Harassment 6. Dishonesty etc

GCTI reserves the right to terminate a student when such action is to the best interest of the class.

Student Record

All student record will be kept confidential and made available only to the student or any

authorizes person as stated only in writing . Student will be allowed to review their records upon writing request to the administrator. Any deletions or additions to the student’s record must be in writing and must be approved by the administrator. All and any request by the student must be in

writing and forwarded to the administrator for consideration and approval.

Gee’s Career Training

Institute

1822 Featherstone Rd Woodbridge VA 22191

Phone: (703) 910-7239 Fax: (703)910-7238

Statement of Non- Discrimination

Student enrollment at Gee’s Career Training Institute is based on students meeting all school requirements for admission. GCTI make all its business and admission decisions without regards to race, color, sex, age, ethnic or national origin, sexual preference or orientation, disability, veteran or marital status or any other characteristic protected by law.

Program Purpose

To brain and teach qualified person to provide safe, Customer- focused high quality, direct care and services to long term care residents under the supervision of licensed Professionals. Students are expected to abide by GCTI policies and procedures. Any student who does not uphold the school standards will not graduate and will not receive any refund. Students are expected to demonstrate responsible and acceptable behavior while in training.

GCTI expects students to:

1. Arrive to class on time and prepare to learn.

2. Ask question or voice any concern regarding the program 3. Dress appropriately and professionally

4. Conduct him/her elf in a respectable and professional manner 5. Turn in all class assignments

6. Participate in class activities e.g. vital sign, bed making etc. 7. Participate in class activities e.g. vital sign, bed making etc. Achieve a grade of 80% of higher on all quiz and final exam.

Fees and Payment Policy

Program fee is paid in advance. Fee includes books, uniform, CPR/FA. Payment is made payable to GCTI, by check or money order. All cash payment will be given a receipt. Credit cards are accepted.

You may be allowed to attend classes on promissory note after a down payment of least $250.00 of the tuition. However, full payment must be made before the end of the course. Any balance due on the course will be assessed a 10% late fee and must be paid in full before certificate can be issued to student.

Dress Code

uniform such as scrubs can be worn during classroom lecture.

Employment Assistance

It is the responsibility of each student to secure employment upon successful completion of the program. We will provide employment assistance upon graduation. However, YOU HAVE THE CHOICE TO WIRK WITH ANY employment agencies or organizations.

Gee’s Career Training

Institute

1822 Featherstone Rd Woodbridge, VA 22191

Phone (703) 910-7239 Fax (703) 910-7238

TO ALL STUDENTS

This Background check is done on all students to assure our

clinical site that our students are safe to practice as students.

You do not need to fill out the form; it will be done by computer

submission. Attached is a sample of the computer submitted

form.

Thank you.

Gee’s Career Training Institute

Woodbridge VA 22191

Phone: (703) 910-7239 Fax: (703)910-7238

REQUIREMENTS COMPLETED IN ORDER TO GO TO CLINICALS:

• ALL TUITION PAID IN FULL

• PPD/CHEST XRAY DONE AND COPY OF DOCUMENTATION IN STUDENT FILE

• PERSONAL MEDICAL MALPRACTICE INSURANCE WITH COPY OF CERTIFICATE IN STUDENT FILE

• 80% CLASSROOM WORK GRADE

• AT LEAST 80 HOURS OF CLASSROOM ATTENDANCE AND WORK TO INCLUDE CPR CERTIFICATION

• SCHOOL UNIFORM, MANUAL BLOODPRESSURE CUFF, SEPARATE STETHOSCOPE; WATCH WITH SECOND HAND, BLACK PEN, SMALL POCKET NOTE BOOK

REQUIREMENTS COMPLETED IN ORDER TO GRADUATE: ALL ABOVE ITEMS PLUS:

• SATISFACTORY CLINCAL GRADE 80% AND ABOVE

• 40 HOURS OF CLINICAL ATTENDANCE

I AGREE TO THE ABOVE REQUIREMENTS FOR THE COURSE AND I UNDERSTAND IF

REQUIREMENTS ARE NOT FULFILLED AS STATED ABOVE I MAY NOT ATTEND CLINICALS AND/ OR GRADUATATE UNTIL THEY ARE FULFILLED.

CLINICALS MISSED FOR NON-COMPLIANCE WILL BE REQUIRED TO BE MADE UP WITH THE NEXT CLINICAL THAT FORMS AND/ OR AS SPACE PERMITS.

NAME PRINTED: __________________________________________________ SIGNATURE: _____________________________________________________

DATE: ___/___/___

Gee’s Career Training Institute

Woodbridge VA 22191

Phone: (703) 910-7239 Fax: (703)910-7238

PAYMENT AGREEMENT

I, _______________________________________________________________________ (PLEASE PRINT NAME ABOVE)

(HERE AFTER REFERRED TO AS STUDENT) DO HEREBY AGREE TO THE

FOLLOWING PAYMENT AGREEMENT FOR THE NURSE AIDE PROGRAM AT GEE’S CAREER TRAINING INSTITUTE:

TOTAL PROGRAM TUITION $1,450 DOWN PAYMENT (DATE __/__/__) $ _____ BALANCE DUE $ _____ PAYMENT SCHEDULE: (FOUR PAYMENT OF $____________ EACH)

DUE DATE: ________________________AMT. DUE $ _____________________________ DUE DATE: ________________________AMT. DUE $ _____________________________ DUE DATE: ________________________ AMT. DUE $ ____________________________ DUE DATE: ________________________ AMT. DUE $ ____________________________ THE BALANCE DUE MAY BE PAID IN FULL AT ANY TIME PRIOR TO DUE DATES. PAYMENTS MUST BE MADE ON TIME ACCORDING TO THE AGREED SCHEDULE OR STUDENT WILL NOT BE ALLOWED TO CONTINUE IN CLASS.

THE BALANCE DUE MUST BE PAID IN FULL BEFORE STUDENT WILL BE ADMITTED TO CLINICALS AND /OR BEFORE STUDENT WILL RECIEVE FINAL GRADE FOR THE CLASSROOM SECTION OF COURSE. STUDENT WILL NOT BE ABLE TO SIT FOR THE VIRGINIA STATE NURSING ASSISTANT TEST UNTIL ALL FEES DUE

TO GCTI ARE PAID.