FULL-TIME ADULT STUDENT APPLICATION ACCEPTANCE PACKET For completion by Certified Nurse Assistant (C.N.A.) Students Only

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FULL-TIME ADULT

STUDENT APPLICATION

ACCEPTANCE PACKET

For completion by Certified Nurse Assistant

(C.N.A.) Students Only

CONNECTICUT STATE DEPARTMENT OF EDUCATION

Connecticut Technical High School System

Middletown

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Certified Nurse Assistant Application Checklist

1.

Complete and sign the enclosed

Application for Admission

.

2.

Include a copy of your

High School diploma

,

transcript

or

GED

Certificate.

3.

Complete and sign the

Full-time Adult Student Information Form.

4.

Bring/mail the

Application for Admission

,

Full-time Adult Student

Information Form

and the

copy of your diploma/GED certificate

to the Adult

C.N.A. Program to which you are applying.

5.

Pay the tuition on or before the first class session begins.

OR

6.

If student meets one of the three qualifications outlined on the

Tuition Waiver

Request Form for Short Term, Extension or Apprentice Program

, complete

a tuition waiver form

at least 4 weeks prior to the start of class

.

Bring/mail

this form with your supporting documentation and your application to the

school

.

7.

If you receive an acceptance letter to the program

, bring the

$50

registration

fee

(cash, certified check, or money order made out to “Treasurer

State of CT”) to the Business Office with a copy of your acceptance letter.

Note: This Registration/application fee is NOT covered by tuition waivers.

Everyone must pay this fee.

8.

If accepted

, complete the

Adult Physical Examination Form

and

bring

on the

1

st

day of class

or make an

afternoon

appointment

for your physical and bring

the date of the appointment. Note: Physical appointments can take several

weeks to schedule…plan ahead.

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Page 1

Application for Student Admission for Full-Time Adult Programs

www.cttech.org

In order to be considered for admission to a Technical High School, applicants must:

 provide the Connecticut Technical High School with a high school transcript or evidence of successfully completing the General Educational Development (GED) test;

 submit signed and dated copy of the Full-time Student Information Sheet included at the end of this application

 Licensed Practical Nurse Program applicants must have taken ATI’s TEAS test. Applicants must also include:

-Resume

-Documentation of having passed the following college level courses ºIntermediate Algebra or equivalent with a “C” or better ºEnglish Composition or equivalent with a “C” or better

Incomplete applications will not be processed

………

Instructions

Complete this application and return the completed application with the required documentation specified above to the appropriate Technical High School addressed to the applicable trade Department Head.

Applicants may have to participate in an interview as part of the application process depending on the trade program.

……….

Student Name: __________________________________________________________ Technical High School applying to: _________________________________________

Adult program applying for:

( ) Aviation Maintenance Technician ( ) Certified Nurse Assistant ( ) Dental Assistant ( ) Medical Assistant ( ) Surgical Technician ( ) Licensed Practical Nurse

For Bristol Technical Education Center, specify program: ____________________________________________

……….

NOTE: Interested candidates, who want to be considered for admission at more than one technical school, must submit a complete application packet to each Technical High School.

It is the policy of the Connecticut Technical High School System that no person shall be excluded from participation in, denied the benefits of, or otherwise discriminated against under any program, including employment, because of race, color, religious creed, sex, age, national origin, ancestry, marital status, sexual orientation, gender identity or expression, disability (including, but not limited to, intellectual di sability, past or present history of mental disorder, physical disability or learning disability), genetic information, or any other basis prohibited by Connecticut state and/or federal

nondiscrimination laws. The Connecticut Technical High School System does not unlawfully discriminate in employment and licensing against qualified persons with a prior criminal conviction. Inquiries regarding the Connecticut High School System’s nondiscrimination policies and practices should be directed to the Superintendent of Schools, Connecticut Technical High School System, 25 Industrial Park Road, Middletown, CT 06457, and/or, regarding race, color, national origin, age, sex and/or disability to the Office for Civil Rights, U.S. Department of Education, Boston, MA 02110-1491, telephone 617.289.0111, fax 617.289.0150, TTY/TDD 877.521.2172. The Connecticut Technical High School System is an equal opportunity/affirmative action employer.

For Technical High School Use Only Application fee submitted ___ High School Transcript or GED submitted ___

LPN program entrance test scores submitted _____ Intermediate Algebra grade submitted ____ English Composition grade submitted ____ Resume submitted ____

Date: _____________ Signature: _________________ Title: ____________________

Applicant’s State Assigned Student ID Applicant Student Identification number:

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Page 2

This application requests information about your national origin, gender, racial or ethnic group, and primary language spoken in the home. Providing this information is voluntary. The information you do provide will be used for record-keeping purposes only; it will not be used as a factor in any action

concerning education, activities or employment.

Personal Information

Full Name: ______________ (_)__________________________________________

(Last) (Maiden) (First) (Middle) Address: _________________________________________________________________________________________

(Box, Apartment, Street Name and Number)

_________________________________________________________________________________________ (City or Town) (State) (Zip Code)

Mailing Address: _________________________________________________________________________________________ (If different) (Box, Apartment, Street Name and Number)

________________________________________________________________________________________ (City or Town) (State) (Zip Code)

Birth Date: ________________ Place of Birth: _________________________________________________________

(Month/Day/Year) (City) (State) (Country) Home Phone: ( ) ______________________________ Other Phone: ( ) __________________________________ Email address: __________________________________

General Information

Gender:



Male



Female

Racial or Ethnic Group:



American Indian or Alaskan Native (1)



Asian American or Pacific Islander (2)



Black (3)



White (4)



Hispanic (5)

Primary Language: ________________________________ High School graduate?



Yes



No

If yes, name of High School: _________________________________________ If no, do you have a GED certificate?



Yes



No

NOTE: A copy of a High School transcript or GED certificate must be included with this application.

Are you a U. S. Veteran?



Yes



No Dates of Service _____________to_____________

Type of discharge: _____________________________________________________________

Are you interested in applying for financial aid (Pell Grant)?



Yes



No

(Note: The Certified Nurse Assistant program does not meet the minimum number of required hours to qualify for a Pell Grant. The applicant can apply for a tuition waiver if receiving aid from a means-tested program as specified on the tuition waiver form or is a senior citizen or has a veteran status.)

Have you attended/applied to another Connecticut Technical High School?



Yes



No

If you answered yes, name of school: _________________________________________________________ Have you ever been convicted of any crime?



Yes



No

Are there any criminal charges pending against you?



Yes



No

If you have answered yes to either of these questions, attach a sheet providing specific information. If conviction of a crime or pending criminal charges is a basis for rejection, you will be notified in writing and you will be provided an opportunity to request reconsideration (see CGS 46a-79 and 80). Failure to disclose a conviction or pending criminal charges will be a basis for rejection, or dismissal if enrolled.

………. Please tell us how you heard about the adult education programs in the CTHSS.

( ) word of mouth

( )

newspaper ads

( )

newspaper articles

( )

cable TV

( )

TV ads

( )

radio ads

( )

career fairs

( )

internet ( ) other __________________________________________________________

I hereby certify that the information provided by me in this application is true, complete and accurate. I understand that applications will not be returned.

Date: _____________________

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Revised 7/2013

Connecticut Technical High School System (CTHSS)

Full-Time Adult Student Information/Financial Obligation Tuition and Fees

The tuition and fee schedule for 2013-2014 academic year as approved by the Connecticut State Board of Education are as follows:

Program Resident/ Non-Resident

Tuition Registration Fees (nonrefundable)

Payment Due Dates

Returning Licensed Practical Nurse

In-State Resident

returning in good standing during the

2012-2013 school year

Total of $10,200 payable over three

semesters

($3,400 per semester)

$50.00 per program

Based on selected payment plan

Returning Licensed Practical Nurse

Non-State Resident

returning in good standing during the

2012-2013 school year

semesters

$50.00 per program

NEW January 2014 Class Licensed Practical Nurse

In-State Resident

newly enrolled

semesters

$50.00 per program

NEW January 2014 Class Licensed Practical Nurse

Non-State Resident

newly enrolled

semesters

$50.00 per program

Returning Aviation Resident

returning in good standing during the

2012-2013 school year

Total of $6,200 payable over two years

($2,066.67 per installment) $50.00 per program August 2013 January/February 2014 New Aviation (starting with December

2013 Class)

Resident

newly enrolled

Total of $6,576 payable over two years

($2,192 per installment) $50.00 per program December 2013 May/June 2014 3rd Installment in 2014-2015

Certified Nurse Assistant Not applicable $1,400 per ten week cohort

$50.00 per academic year

Date of first scheduled class

Dental Assistant Not applicable $3,500 payable over two semesters

Medical Assistant and Surgical Technology

Not applicable $3,500 payable over two semesters

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Revised 7/2013

Connecticut Technical High School System (CTHSS)

Full-Time Adult Student Information/Financial Obligation Tuition and Fees

The tuition and fee schedule for 2013-2014 academic year as approved by the Connecticut State Board of Education are as follows:

Program Resident/ Non-Resident

Tuition Registration Fees (nonrefundable – not covered by tuition waiver)

Payment Due Dates

Certified Nurse Assistant Not applicable $1,400 per ten week cohort

On or before first class session

Acceptable methods of payment

 Bank check or money order made payable to “Treasurer, State of Connecticut” for the exact amount due;

 Cash will be accepted in the school business office only during regular business hours (8:30 a.m. – 4:30 p.m.);

Unacceptable methods of payment  Personal checks;

 Debit and Credit cards;

 Cash (except during normal business hours);

Other financing options (It is the responsibility of the student to initiate and follow up on the methods listed below):

The Connecticut Technical High School System offers other financing options including:

 Tuition Waivers - The Certified Nurse Assistant program does not meet the minimum number of required hours to qualify for a Pell Grant; however, Tuition Waiver is available only for qualified C.N.A. applicants that meet the requirements listed below. Tuition Waiver Request form must be submitted NO LATER THAN four weeks prior to the first class session. A tuition waiver does not cover the Registration Fee.

**Any student failing to pay or be approved for an alternative financing option by the payment due date will be immediately dismissed from their program of study. As regular attendance is a critical aspect of the educational process, students with attendance problems may be dismissed from the program.

Applying for a tuition waiver

Eligible students wishing to apply for a tuition waiver must complete a Tuition Waiver Request form (no later than four weeks prior to the first class session. Download Tuition Waiver Request form.

 Veterans requesting a tuition waiver must attach a copy of their Certificate of Release or Discharge (DD Form 214) (90 days of honorable active duty service in addition to that spent in active duty training and in attendance at military service academies for any war period after August 2, 1990 or engaged in combat or in combat support role in specific conflicts prior to August 2, 1990);

 Senior Citizens – Students age 62 and over requesting a waiver must attach a copy of their proof of age;

 Financial Hardship (ONLY for students enrolled in the Certified Nurse Assistant program) students requesting a tuition waiver MUST provide proof of the student’s or student’s spouse or dependent student’s parent current approval to participate in one or more of the following means-tested benefit programs:

o Supplemental Security Income (SSI) from Social Security Adm. Or State of Connecticut Assistance - not Social Security Income;

o Connecticut Documentation for Food Stamps;

o Free or Reduced Price Lunch;

o Temporary Assistance for Needy Families (TANF);

o Women in Crisis (WIC);

 Unemployment compensation is NOT a means-tested benefit program and therefore is not considered when determining financial hardship;

 Students whose tuition is being paid by another state agency must submit written documentation (i.e. voucher) identifying the agency responsible for payment.

 Students receiving educational assistance benefits under the G.I Bill from the Veterans Administration must submit enrollment verification or training agreement. The student should provide the school Certification Officer, VA Form 22-1999 for submission to the Veterans Administration to receive the education benefits payment form VA.

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Revised 7/2013

Connecticut Technical High School System (CTHSS)

Full-Time Adult Student Information/Financial Obligation Procedures for Withdrawal

In order to officially withdraw from an adult education program in the CTHSS and be considered for a tuition refund, candidates must complete and

submit to the school‘s Guidance Office, the following two documents available from the district’s Adult Education webpage (www.cttech.org/AdultED):

1. Student Withdrawal Form

2. Request for Tuition Refund Form (Appendix IX)

Upon approval of the Student Withdrawal Form by a school administrator (principal or assistant principal), students may be eligible for a tuition refund.

Eligibility for Tuition Refunds

 Except for withdrawal due to military action or serious illness, if the Student Withdrawal Form is received from the student prior to the first scheduled class session, the student is eligible for a 100% tuition refund.

 Except for withdrawal due to military action or serious illness, If the Student Withdrawal Form is received from the student after the first scheduled class session, but prior to the fourteenth (14th) calendar day from the first scheduled class session, the student is eligible for a 60% tuition refund.

 Except for withdrawal due to military action or serious illness, if a Student Withdrawal Form is received after the fourteenth (14th) calendar day from the first scheduled class session; the student is not eligible for a tuition refund.

 All requests for tuition refunds due to military action and supported by written documentation from the military are eligible for 100% tuition reimbursement;

 All requests for tuition refunds due to serious illness and supported by written documentation from a medical professional are also eligible for 100% tuition reimbursement;

 Except for military action or serious illness, no refunds will be provided to students who are dismissed from their program of study due to issues with attendance, unsatisfactory educational performance or violation of the district’s discipline policy as detailed in the 2013-14 Full-Time Adult Student Handbook.

Processing of Tuition Refunds

If the student meets the eligibility requirements for a tuition refund, the Request for Tuition Refund Form (Appendix IX) completed by the student will be forwarded from the school administrator to the school’s business office and then to the State Department of Education’s (DOE) Payments Unit.

The SDE Payments Unit will then issue a state invoice utilizing the State of Connecticut’s official accounting system (CORE-CT) and transmits the invoice to the State Comptroller for issuance of a refund check payable to the student within the state’s payment timelines (currently net 45 days).

I have read and understand the above:

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Connecticut Technical High School System

Student’s Name _____________________________ Student ID # ______________ Date of Birth _________________ Address ____________________________________ City __________________ State ___________ Zip __________

Student’s Home Phone ____________________ Cell __________________ Alt/email ________________________ Emergency Contact Name _________________________ Phone (1) __________________ (2) _________________

( )Aviation Maintenance Technician ( ) Certified Nurse Assistant ( ) Dental Assistant ( ) Licensed Practical Nurse ( ) Medical Assistant ( ) Surgical Technician

TO THE EXAMINING PHYSICIAN/HEALTHCARE PROVIDER: Date of Exam: ____________________

On the basis of my health assessment and physical exam: □ Student denies Latex Allergy Student is clear to participate in clinical nursing courses with no restrictions (please check) □ Yes □ No IF NO, please explain the nature of the restrictions/limitations related to the delivery of patient care:

______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________

IMMUNIZATION ASSESSMENT

Please refer to the CDC Healthcare Personnel Vaccination Recommendations at http://www.immunize.org/catg.d/p2017.pdf

TITERSMUST BE POSITIVEPER LABORATORY STANDARD; REPORT MUST ACCOMPANY THIS FORM. If titers

show student is not immune, please state plan of how non-immunity will be addressed.

RUBEOLA (MEASLES) TITER ____________Immune? Yes ___ No ____

May be Qualitative or Quantitative Titer Laboratory report must be attached

RUBELLA (GERMAN MEASLES) TITER _______Immune? Yes ___ No ___ May be Qualitative or May be May May be Qualitative or Quantitative Titer Laboratory report must be attached

MUMPS TITER _____ Immune? Yes _____ No _____

May be Qualitative or Quantitative Titer Laboratory report must be attached

VARICELLA (CHICKEN POX) Provide Evidence of Immunity by:

□

Physician diagnosis or

□

Titer or

□

Lab confirmation of diseaseor

□

2 doses of varicella vaccine > 28 days apart

May be Qualitative or Quantitative Titer Laboratory or physician report of diagnosis must be attached

TETANUS/DIPHTHERIA/PERTUSSIS (Tdap/Td) Date of Tdap/Tetanus/Td Booster ___________(date given must be within last 10yrs)

All healthcare personnel (HCP), regardless of age, should receive a single dose of Tdap as soon as feasible if they have not previously received Tdap and regardless of the time since last Td dose; then they should receive Td boosters every 10 years thereafter. For further information see: http://www.cdc.gov/vaccines/pubs/vis/downloads/vis-td-tdap.pdf

If No, include plan for or evidence of receipt of 2 doses of MMR Vaccine; refer to CDC guidelines

http://www.immunize.org/catg.d/p2017.pdf

If No, include plan for or evidence of receipt of 2 doses of MMR Vaccine; refer to CDC guidelines

http://www.immunize.org/catg.d/p2017.pdf

If No, include plan for or evidence of receipt of 2 doses of MMR Vaccine; refer to CDC guidelines

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ANNUAL ASSESSMENTS/REQUIREMENTS:

Hep. B SERIES: _____________ ___________ __________

Per protocol 1st dose 2nd dose 3rd dose

Hep. B Surface Antibody Titer _______________________ Immune? Yes ______No_____ (if no, revaccinate with add’l 3 dose series)

>10mlU/mlis positive/Immune (1-2 months following Dose #3) Laboratory report must be attached

TST (Tuberculosis Skin Test required yearly) _____________ ______________ _______________

(TST must be performed in accordance with requirements of clinical facilities) Date Given Date Read Results

If previously positive TST(Year 2 and forward) complete Annual TB screening form:

□

Student shows no evidence of TB symptoms

If new positive TST provide:

□

chest x-ray report showing no evidence of active TB disease Attach Official report(s)/record(s)

Influenza Vaccination is required yearly; please provide evidence of vaccination per CDC protocol _____________

Official report/record must be attached Date Given

___________________________ _______________________________ _______________________ _________

Healthcare Provider Print Name Healthcare ProviderSignature DEA Number DATE Address: _______________________________________________________________Telephone ( ) ________- __________

6/2013 □ Student has been determined to be a non-responder and is aware of CDC recommendations for exposure to Hepatitis B surface antigen positive blood, refer to CDC guidelines

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Connecticut Technical High School System

Student Statement of Responsibility

I understand that I must submit a completed Health Assessment form prior to

participation in any clinical experiences.

I am aware that if my health status should change in a way that would impact my ability

to perform in the nursing program, I must notify the Director/Administrator of the

program immediately. The need for additional clearance will be determined at that time.

_____________________________

Student Name (Please Print)

_____________________________

___________

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Connecticut Technical High School System

Annual Tuberculin Screening Form

Student Name: _________________________________________

Date: __________

History of Positive Tuberculin Skin Test:

YES

NO

History of BCG Vaccine:

YES

NO

Date of last chest x-ray: ____________________ Results: ____________________

Current Symptom Assessment:

Signs and symptoms of active TB:

YES

NO

If yes, indicate medical treatment plan:

______________________________________________________________________________

Student is cleared to attend clinical assignments with no restrictions:

YES

NO

____________________________________________

_______________

Primary Care Provider (Print Name)

Date

____________________________________________

_______________

Primary Care Provider Signature

Telephone Number

____________________________________________

Street Address

____________________________________________________________________________

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Information for Students and Healthcare Providers about Immunity Assessment/Titers for

Nursing Students

MMR:

the MMR titers once determined do not have to be rechecked, regardless of when

drawn

. It is possible that they may be lowered during pregnancy, but otherwise should remain

consistent. In this case a

qualitative

titer is acceptable. In a situation whereby a student was

vaccinated in year one of the program, titers should be validated in year 2 of the program.

Varicella:

Quantitative

titers should be drawn once;

if immunity is determined to be present

then student does not need titer drawn for second year.

In any case if student is immunized

year 1 then titer should be drawn year 2, the key is QUANTITATIVE titer vs. qualitative (i.e.

EIA index is not a quantitative titer).

Hepatitis B: Very Tricky. Some people NEVER develop immunity; some can lose immunity

over time, thereby requiring a booster. So with this in mind:

Those students that go through their series of injections during or in preparation for year one of

the program, should then go on to have a QUANTITATIVE test for year 2. This value must

exceed 10 milliunits / ml to establish immunity. If immunity is not established, the student

should have a booster and have immunity rechecked.

If a student produces a recent titer (less than 5 years old) that establishes immunity this

will suffice for both years. In the event that a student produces a titer 5 years or older a

quantitative titer is required for year 1.

The student that comes to us stating they have had the series in the past, regardless of proof of

the shots, still need to have a quantitative titer done to establish immunity. For all intents and

purposes for any student (even those who are readmitted or transferred) this should suffice as

long as we were within a 5 year window of time from the initial establishment of immunity.

If a student refuses to receive Hepatitis B immunization a waiver must be signed and kept on file.

PPD: Must be updated on a yearly basis in order to maintain status in the program, exceptions:

Students who have received BCG immunization should not get a PPD

Students who have had a positive PPD

Students who are immunosuppressed, have cancer, or are on steroids should not get a PPD

If PPD cannot be obtained because of the above, student should have a SINGLE chest x-ray to

document freedom from disease. Thereafter, on a yearly basis, a note must be received from the

Healthcare provider stating that the student shows no evidence of symptoms of TB.

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REFUSAL FOR USE OF HEPATITIS B VIRUS VACCINE

I understand that due to my occupational exposure to blood or other potentially infectious

materials I may be at risk of acquiring hepatitis B virus (HBV) infection. However, I decline

hepatitis B vaccination at this time. I understand that by declining this hepatitis B vaccination at

this time, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I

continue to have occupational exposure to blood or other potentially infectious materials and I

want to be vaccinated with hepatitis B vaccine, I can then receive the vaccination series.

NAME: ____________________________ DATE: _

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Revised 9/2011

1

CONNECTICUT TECHNICAL HIGH SCHOOL SYSTEM – ADULT EDUCATION

TUITION WAIVER REQUEST

SHORT-TERM, APPRENTICE* OR EXTENSION* PROGRAMS

Qualified Certified Nurse Assistant (C.N.A.) students complete this form to request a tuition waiver *Apprentice and Extension students can apply for a waiver only if they meet the Veteran or Senior Citizen requirements. Requests due at the School:

-The student encloses the waiver request and supporting documentation with the program application and bring/mail to the Program of his/her choice for review and approval at least two weeks prior to the first class session;

-The assigned school staff will forward the request to Central Office by the due dates specified under the school completion section.

If the request is denied, tuition is due on or before the first class session, or if the student is already enrolled,

tuition is due on the day of their next class session following the date of the denial letter.

STUDENT INFORMATION

Date Submitted _________________Student Type ____________________________________

Apprentice, Extension, C.N.A. Short Term

Student Name ______ Student Identification Number

Street Address _______________________________City, State,_______________________________

Check reason type and attach copy of appropriate documentation:

TO BE COMPLETED BY SCHOOL

School Name ________________________

Waiver Number ________________

Course Number/Name ______________________ Course Start Date ________________

Supervisor Signature ________________________________

Date _____________

Requests due at Central Office (forwarded by the school staff with appropriate documentation/signatures).

SEND ATTENTION OF: Ada Kercadó, CTHSS, 25 Industrial Park Road, Middletown, Connecticut

TO BE COMPLETED BY CENTRAL OFFICE

Approved _______

Denied _______

Superintendent or Designee_______________________________ Date___________

Type of Waiver Request Acceptable Documentation



Veteran 1) DD-214 with proof of honorable discharge from Active Duty Service (Active Duty Training [ADT]

does not qualify for tuition waiver); OR 2) Proof of current active duty service.



Financial Hardship

(Apprentice or Extension Students do not qualify)

Proof that student (and/or spouse or dependent student’s parent) is a current recipient of benefits from one of the following means-tested benefit programs: Supplemental Security

Income (SSI); Connecticut Documentation for Food Stamps, Free or Reduced Price Lunch, TANF, WIC. (Unacceptable Documentation: copy of benefit member card, copy of Husky medical program participant

documentation.) NOTE: Unemployment Compensation is NOT a means-tested benefit program.



Senior Citizen Valid photo ID with DOB showing student is age 62 or older based upon seat availability.

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Revised 9/2011

2 PLEASE NOTE: A COPY OF THE APPLICATION/REGISTRATION FORM MUST BE ATTACHED

CONNECTICUT TECHNICAL HIGH SCHOOL SYSTEM - ADULT

EDUCATION

TUITION WAIVER REQUEST

SHORT-TERM, APPRENTICE OR EXTENSION PROGRAMS

Important information regarding documentation that should be attached to Veteran’s tuition waiver

requests:

Copy of DD-214 with proof of honorable discharge

OR

Proof of current active duty service

Important information regarding documentation that should be attached to support financial hardship

tuition waiver requests:

Please note changes in the acceptable documentation to support a student’s waiver request. Student (and/or spouse

or parent(s) if the student is a dependent student) must provide documentation that they are currently receiving

benefits from one of the following means-tested benefit programs in order to be eligible for tuition waiver:

*Supplemental Security Income (SSI) [SSI from Social Security Adm. or State of Connecticut Assistance]

Food Stamps (State of Connecticut)

Free or Reduced Price Lunch (State of Connecticut)

TANF (State of Connecticut)

WIC (State of Connecticut)

Students should provide a copy of their benefit approval letter from the agency providing the assistance

which lists the period of eligibility.

Copies of only the member’s benefit card(s) are not acceptable

documentation. Those

not

receiving benefits from one of the above sources, but enrolled in the Husky medical

program are not eligible for waiver.

*Only Supplemental Security Income (SSI) benefit is considered for hardship. Regular monthly Social Security

Benefits is not a means-tested benefit program. Therefore, the documentation from the Social Security

Administration will need to state: Supplemental Security Income benefits

not

monthly Social Security Benefits;

unless the applicant can provide proof that he/she is a current recipient of benefits from one of the State of

Connecticut means-tested programs, cash assistance, food stamps, free or reduced price lunch, TANF, or WIC.

Please do not collect or submit copies of income tax returns, W-2 forms, or any other documentation that is not

proof of receipt of assistance from any of the programs listed above.

Unemployment compensation is not a means-tested benefit program and is not considered when determining

financial hardship.

Important information regarding documentation that should be attached to support senior citizen tuition

FULL-TIME ADULT STUDENT APPLICATION ACCEPTANCE PACKET For completion by Certified Nurse Assistant (C.N.A.) Students Only

FULL-TIME ADULT

Application for Admission

and the

, complete

(cash, certified check, or money order made out to “Treasurer

bring

www.cttech.org

Incomplete applications will not be processed

Adult program applying for:

Applicant’s State Assigned Student ID Applicant Student Identification number:

Personal Information

Full Name: ______________________ (_________________)__________________________________________________

General Information

Racial or Ethnic Group:

………. Please tell us how you heard about the adult education programs in the CTHSS.

Connecticut Technical High School System (CTHSS)

Full-Time Adult Student Information/Financial Obligation Tuition and Fees

2012-2013 school year

newly enrolled

returning in good standing during the

Revised 7/2013

Connecticut Technical High School System (CTHSS)

Full-Time Adult Student Information/Financial Obligation Tuition and Fees

Acceptable methods of payment

Other financing options (It is the responsibility of the student to initiate and follow up on the methods listed below):

Revised 7/2013

Connecticut Technical High School System (CTHSS)

Full-Time Adult Student Information/Financial Obligation Procedures for Withdrawal

Eligibility for Tuition Refunds

Processing of Tuition Refunds

Connecticut Technical High School System

IMMUNIZATION ASSESSMENT

Please refer to the CDC Healthcare Personnel Vaccination Recommendations at http://www.immunize.org/catg.d/p2017.pdf

May be Qualitative or Quantitative Titer Laboratory report must be attached

If No, include plan for or evidence of receipt of 2 doses of MMR Vaccine; refer to CDC guidelines

ANNUAL ASSESSMENTS/REQUIREMENTS:

>10mlU/mlis positive/Immune (1-2 months following Dose #3) Laboratory report must be attached

Connecticut Technical High School System

program immediately. The need for additional clearance will be determined at that time.

Signs and symptoms of active TB:

Nursing Students

vaccinated in year one of the program, titers should be validated in year 2 of the program.

EIA index is not a quantitative titer).

exceed 10 milliunits / ml to establish immunity. If immunity is not established, the student

The student that comes to us stating they have had the series in the past, regardless of proof of

PPD: Must be updated on a yearly basis in order to maintain status in the program, exceptions:

document freedom from disease. Thereafter, on a yearly basis, a note must be received from the

hepatitis B vaccination at this time. I understand that by declining this hepatitis B vaccination at

NAME: ____________________________________________ DATE: _________________

CONNECTICUT TECHNICAL HIGH SCHOOL SYSTEM – ADULT EDUCATION

Qualified Certified Nurse Assistant (C.N.A.) students complete this form to request a tuition waiver *Apprentice and Extension students can apply for a waiver only if they meet the Veteran or Senior Citizen requirements. Requests due at the School:

If the request is denied, tuition is due on or before the first class session, or if the student is already enrolled,

Apprentice, Extension, C.N.A. Short Term

Student Name __________________________ Student Identification Number ____________________

SEND ATTENTION OF: Ada Kercadó, CTHSS, 25 Industrial Park Road, Middletown, Connecticut

TO BE COMPLETED BY CENTRAL OFFICE

Revised 9/2011

CONNECTICUT TECHNICAL HIGH SCHOOL SYSTEM - ADULT

tuition waiver requests:

Food Stamps (State of Connecticut)

documentation. Those

Administration will need to state: Supplemental Security Income benefits

Please do not collect or submit copies of income tax returns, W-2 forms, or any other documentation that is not

waiver requests:

Full Name: ______________ (_)__________________________________________

NAME: ____________________________ DATE: _

Student Name ______ Student Identification Number