NURSING ASSISTANT TRAINING PROGRAM

NURSING ASSISTANT TRAINING PROGRAM

ADMISSION APPLICATION

Name:

Date of Birth: SS#:

Address: City:

State: Zip: Phone: C( ) H ( )

Email Address: @ Occupation: Employer: Address: _ EMERGENCY CONTACT: Name: Relationship; Address: City:

State: Zip: Tel:( )

EDUCATIONAL BACKGROUND (HIGHEST EDUCATION ATTAINED): ATTENDED HIGH SCHOOL HIGH SCHOOL DIPLOMA/ GED SOME COLLEGE ASSOCIATE/ BACHELOR’S DEGREE POST COLLEGE

WORK EXPERIENCE: (PLEASE LIST BEGINNING WITH MOST RECENT)

YEAR JOB TITLE OCCUPATION/ EMPLOYER DUTIES & RESPONSIBILITIES

How did you find out about Nightingale Healthcare Professionals?: Personal Referral (name)

o o o

Faxed/ Posted flyer (place) Other (please be specific)

I hereby certify all the above to be true and correct to the best of my knowledge Today’s Date:

Signature of Applicant

NURSING ASSISTANT TRAINING PROGRAM

ENROLLMENT AGREEMENT

Name:

Date of Birth: SS#:

Address: City:

State: Zip: Phone: C( ) H( )

TOTAL CLOCK HOURS OF INSTRUCTION: 150 HOURS 21 DAYS (DAY PROGRAM) 30 DAYS (EVENING PROGRAM) PROGRAM LENGTH:

SPECIFIC TIMES OF CLASS ATTENDANCE (DAY PROGRAM): 8:00am–4:30pm SPECIFIC TIMES OF CLASS ATTENDANCE (EVENING PROGRAM): 3:00 pm – 8:00 pm TYPE OF DOCUMENT AWARDED UPON COMPLETION:

Upon successfully completing all requirements of the course, the student will receive a Certificate of

Completion.

Scheduled Start Date: Scheduled Completion Date: FEES AND CHARGES

Application Fee (non-refundable) $ 150.00 Nursing Assistant Training Program Fee includes: $ 900.00

Tuition Fee Textbook Skills CD O o o $1,050.00 Total Nursing Assistant Training Program Fee

Additional Fees-Students Responsibility ARC Testing Fee Uniforms

Stethoscope (optional) Gait Belt (optional) White Shoes

Watch with second hand O o o o o o

CERTIFIED NURSING ASSISTANT TRAINING

By attending the 21-day full-time or 30 day (Evenings Only) part-time Nursing Assistant training class at Nightingale Healthcare Professionals and becoming a CNA by passing the ARC

competency exam, graduates can begin working at the entry level of the healthcare field; a person can literally be on their way, climbing the career ladder that leads to height sin the medical field only limited by the student themselves. A firm healthcare training background provides the basis for a transition in to other patient care areas including LVN, RN, nurse practitioner, PA ,etc.

CNA training is a truly viable option for all participants:

• The U.S. Bureau of Labor Statistics estimates that healthcare related occupations are and will continue to be the fastest growing area of employment for the next decade.

The training period required is 150 hours; there are no pre-requisites, no requirements of a high school diploma or GED. The hours are broken down into 50 hours theory and 100 hours of hands-on training; we train with residents who reside in area skilled nursing facilities.

The maximum student teacher ratio is 15:1 thereby allowing those students requiring special attention to receive it. We truly have a "no student left behind" philosophy. Employment is usually obtained immediately after passing the American Red Cross Certification Test. We offer assistance with job placement as well.

CNA literally work any given hours of the day or night. Many careers are restricted today time and evening hours, not so with the CNA. There are night shifts as well. Most facilities are so short staffed that there is a lot of overtime available which is paid at a rate of time and a half for 9 to 12 hours and double time for13 to 16 hours.

The starting salary for CNA's is $13 to $14 an hour with benefits for those who work a full time schedule. • • • • •

There are also other reasons for referring your clients to the CNA training program offered by Nightingale Healthcare Professionals:

1. The training location, at 8105 Edgewater Dr. Suite 290, Oakland is on a major bus route for those traveling by public means. For those driving, there is plenty of free parking-no searching for parking places on the street or having timed meters.

We offer job assistance by providing students with verified job leads, in the form of phone numbers, addresses and contact person(s) to over 50 nursing homes in the bay area. We offer resume preparation and coaching, interview skills development and proper attire. 2.

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CERTIFIED NURSING ASSISTANT TRAINING

4. The classes are small with 15:1 student/instructor ratios, and individualized attention. 5. We have excellent relationships with the Nursing Facilities where students receive their

clinical training, and where some students have been placed in employment capacities. For enrollment and training questions, contact our office or our school Director, Veronica Taylor-Henry, RN, BSN, PHN at 510-553-1800.

Cost for the Program is Fees Breakdown:

$150 Application Fee

$250 $150

Deposit

Supplies (books and course materials)

$500 Tuition

TotalFees $1,050

Other costs to student:

$90 American Red Cross Competency Testing Fee

$75 (Includes Mandatory Book)

$49

BLS (CPR Certification) OPTIONAL

Live Scan

NOTE: These prices are based on prices from Uniform Advantage on Christie Ave in Emeryville. They will give 10% off of these prices if you tell them you will be a NHP Student. You may choose to get your supplies from another store if you wish.

Analog watch with second hand Wine uniform (scrubs)

$23.00 $30.00 White shoes $30.00 Stethoscope-B/Pcuff (combination) $40.00 Gait Belt $12.99 Requirements forProgram:

Pass a criminal background check. Obtain TB test and clearance(Must be within the past year) Obtain a physical (Must be within the past year)and a flu shot during the months of Nov 1 thru March 31st

only (flu season)

NightingaleHealthcareProfessionals"YourFutureinHealthcareStartsNow!"

8105 EdgewaterDrive,Suite290, Oakland,CA94621 (510)553-1800 fax(510)553-1818 1617CanyonDrive,Suite101,Pinole,CA94564(510)724-6929Fax(510) 724-6929 \\

MUST have TB test, Livescan, Physical and Flu Shot (flu season – Nov 1 thru Mar 31) Make arrangements to complete them before 1st day of class.

Cannot miss theory hours to get tests completed. TBTESTSAVAILABLEATTHISLOCATION:

Must call at 5:45 pm and someone will call you back for appointment

Berkeley Free Clinic

2339 Durant Avenue

Berkeley,CA 94704

(510) 548-2570

Free

Open daily

LIVESCAN AND PHYSICALSAVAILABLEAT THIS LOCATION: No appointment needed

Occupational Testing Center

2475 West 12

Street

Oakland, CA 94607

(510) 836-0448

Physical $49 Open Mon – Sat

Livescan $49 Open Mon - Sat

Dr. Konstantin

2584 MacArthur Blvd.

Oakland,CA 94602

(510) 530-5400

(510) 530-2921 FAX

$40 for all 3 (best value)

$20 TB test only

$30 Physical only

Flu shot free with TB or Physical

Open Mon – Fri 10 am till 5 pm No appointment needed

MedicalExaminationReport

S.S. # DATE OF BIRTH:

Please have the examiner fill out the information requested in each area. In some cases only a MD may verify treatment of medical clearance to participate in the Nursing Program. Turn in completed form to NHP administrative office on the first day of class.

Please Circle: MALE FEMALE DATE OF EXAMINATION:

HEIGHT: WEIGHT:

PULSE: /MIN RESP BLOOD PRESSURE: VISUALACUITY:

RT EYE: LEFT EYE: VISUAL ACUITY WITH CORRECTIVE LENS : RT EYE: LEFT EYE: CHECKLIST NORMAL ABNORMAL _{OF ABNORMAL FINDINGS} DETAILED DESCRIPTION

HANDS/SKIN HEADEYES EAR/NOSE/THROAT/MOUTH NECK/NODES CHEST/LUNGS CARDIOVASCULAR ABDOMEN MUSCULOSKELETAL NERVOUS SYSTEM

STUDENT EXAMINATION OUTCOME

I have examined

and found that the student is FREE of

(Student's Name)

Communicable diseases and does not have any condition that would create a

hazard to himself/herself, fellow students, patients, and visitors.

I have examined

and found a condition at

(Student's Name)

this time that appears to PREVENT this person from fulfilling the requirements

as described above.

(Please describe condition and recommendations below.)

PHYSICIAN'S PRINTED NAME:

PHYSICIAN'S SIGNATURE:

ADDRESS:

TELEPHONE NUMBER:

TB TEST Intradermal Skin Test (PPD Mantoux)

Result Date Tested

If Positive skin test, a medical physician must enter in the following information: Date of Chest x-ray: (Within the Past Year) Result:

(Chest X-ray and Questionnaire must be done annually)

Has this patient been prescribed any Chemotherapy to treat B ? What medications are Prescribed and what prescription/regimen?

STATE OF CALIFORNIA BCIA 8016

(orig. 4/2001; rev. 01/2011) DEPARTMENT OF JUSTICE

REQUEST FOR LIVE SCAN SERVICE Applicant Submission

Certification A1226

Authorized Applicant Type

ORI(Code assigned by DOJ)

Certified Nurse Assistant (CNA) or Home Health Aide (HHA)

Type of License/Certification/Permit OR Working Title (Maximum 30 characters - if assigned by DOJ, use exact title assigned)

Contributing Agency Information:

California Department of Public Health (CDPH) 03314

Agency Authorized to Receive Criminal Record Information MS 3301, P.O. Box 997416

Mail Code (five-digit code assigned by DOJ)

Street Address or P.O. Box Sacramento

Contact Name (mandatory for all school submissions)

CA 95899-7416

State

City Zip Code Contact Telephone Number

Applicant Information:

First Name Middle Initial

Last Name Suffix

Other Name

(AKA or Alias) Last First Name

Suffix

Sex _{Male Female}

Date of Birth

Driver's License Number Billing

Number Misc. Number

Weight Eye Color Hair Color

Height

(Agency Billing Number)

Place of Birth (State or Country) Social Security Number (Other Identification Number)

Home

Address Street Address or P.O. Box State Zip Code

City

Your Number: _{Level of Service: DOJ FBI}

OCA Number (Agency Identification Number)

If re-submission, list ATI number:

(Must provide proof of Rejection) Original ATI Number

Employer (Additional response for agencies specified by statute):

Nightingale Healthcare Professionals Employer Name

8105 EdgewaterDr.,Ste.290

Mail Code (five-digit code assigned by DOJ)

Street Address or P.O. Box

Oakland CA 94621

State Zip Code Telephone Number (optional)

City

Live Scan Transaction Completed By:

Name of Operator Date

Amount Collected/Billed

Transmitting Agency _LSID ATI Number