Become a CNA

The nursing assistant performs assigned tasks for patients/residents which may include the following:

• Taking Vital Signs (blood pressure, pulse, temperature and respirations)
• Feeding
• Bathing
• Toileting
• Sitting/Monitoring
• Grooming (hair care, nail care, dressing, etc.)

• Long-term Care Facilities
• Hospitals
• Private Homes
• Rehabilitation Centers
• Home Health Agencies

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CNA/Nurse Aide Training Program

Section I

Section II

Section III

Step IV

Step V

• General Information
• Background
• Legal
• Personal Information
• Program Information & Signature

General Information

By checking this box the applicant agrees that this application was completed by the applicant in its entirety. The applicant further agrees that no assistance from anyone other than the applicant was given to complete this application.

I agree

Full Name

Mailing Address (Number and Street, City and State, ZIP)

Telephone Number

Email

Social Security Number

Emergency Contact Information

Full Name

Relationship

Phone Number

Educational Background

Highest Level of Education Completed

High School Diploma GED (High School Equivalency) College None of the above

Employment

Current Employer (if applicable)

Address

Start Date

End Date

Position Held

Phone Number

Salary

Legal

Have you ever been convicted of theft/abuse/neglect of an elderly person or child?

No Yes

If Yes, list conviction

Court of Conviction

Date of Conviction

Has any health-related licensing, certification or disciplinary authority taken adverse action (revoked, annulled, cancelled, suspended etc.) against you?

Yes No

If yes, indicate the type and number of license/certificate

Personal Information

The following information does not determine your acceptance into the program. This information is used for certification and testing identification, statistical data and/or  financial  information.

Race

African American

Caucasion

Asian

Hispanic

Native American

Other

Sex

Male Female

Date of Birth

Height

Eye Color

Brown Blue Green Gray Hazel Other

Other Information

How did you hear about CHAT?

Internet Search

Facebook

Instagram

Brochure or Flyer

Referral (person)

Health Fair or Job Fair

Other

After graduation I plan to: (check what applies)

Work in a full-time position

Work in a part-time position

Go back to school

Undecided

If planning to work after graduation, what shift do you prefer?

Day

Evening

Night

Program Information

I understand that the Nurse Aide Training program is a 120 hour program. Admission can be full-time or part-time, day or evening. I further understand that the program includes training in the following settings: classroom instruction, hands-on laboratory training, and clinical training in a long-term care facility.

Do you prefer day or evening classes?

Full-Time (Days) 9am-3pm Part-time (Evening) 5pm-9pm

Tuition & Costs

TOTAL Program Cost: $3,000 I understand that tuition for the Nurse Aide Training program is guaranteed for the period of enrollment for both full-time and part-time students. Tuition: $3,000 (includes a NON-Refundable application fee of $40.00)

1. Tuition
2. CPR Certification
3. Liability Insurance
4. Student ID (for clinical site)
5. Practice Test for State Board Exam
6. Textbook
7. Workbook
8. Stethoscope
9. Blood Pressure Cuff
10. Gait Belt
11. State Board Exam (Knowledge and Skills Test
12. State Board Remediation
Additional Requirements/Supplies at the Student’s Expense:
13. Tennis shoes or nursing shoes (for clinical site)
14. Wrist watch (must have a second hand)
15. Background Check (within 30 days of enrollment)- provided by the institution
16. Evidence of screening for tuberculosis or chest x-ray showing no active TB (within 12 months)-at the student’s expense

Cancellation | Withdrawal | Refund Policy

In the event a student withdraws from the institution, the student MUST provide the institution with a written withdrawal notice. The notice will be effective the date the institution receives it or if no notice is given, the effective date will be the last day the student was in attendance. If a student is expelled, the last day of attendance shall be the date on the expulsion notice or the date the student fails to return from an approved leave of absence. For tuition paid or to be paid by student assistance programs sponsored by one or more governmental or private agencies or organization, including employer provided financial assistance, and the institution, as a condition of establishing eligibility for its students to participate in such programs, is required to adhere to a refund policy prescribed by the sponsor of the student assistance. For students not affected by the above, based on fees that the student was charged, the institution’s refund policy produces a refund which equals or exceeds the amount which would be calculated by application of the following:

Withdrawal Period	Refund Amount
Withdrawal on or before the first day of class or failure to begin class	FULL Refund less an administrative fee of one hundred dollars ($100.00)
Withdrawal after classes have started and before ten percent (10%) of the enrollment period has lapsed, a student: ·        Withdraws ·        Drops out ·        Is Expelled ·        Fails to attend class	Seventy-five percent (75%) refund of all amounts paid or to be paid by or on behalf of the student for the period, less an administrative fee of one hundred dollars ($100.00)
Withdrawal after ten percent (10%) of the enrollment period has lapsed and before twenty-five percent (25%), a student: ·        Withdraws ·        Drops out ·        Is Expelled ·        Fails to attend class	Twenty-five percent (25%) refund of all amounts paid or to be paid by or on behalf of the student for the period, less an administrative fee of one hundred dollars ($100.00)
Withdrawal after twenty-five (25%) of the enrollment period, a student ·        Withdraws ·        Drops out ·        Is Expelled ·        Fails to attend class	NO REFUND The student may be deemed obligated for one hundred (100%) of the tuition, fees and other charges assessed by the institution

In the event the institution has to discontinue classes during an enrollment period which results in the student’s inability to complete classes for which the student was charged, the institute will provide the student with a FULL refund.

Other

Transferability of Contact Hours Disclosure Comprehensive Health Academy of Tennessee is a special purpose institution.  That purpose is to provide foundational skills and education to students in preparation for entry into the workforce as Nursing Assistants. This purpose does not include preparing students for further college study. Students should be aware that transfer of credit is always the responsibility of the receiving institution.  Whether or not credits transfer is solely up to the receiving institution. Any student interested in transferring credit hours should check with the receiving institution directly to determine to what extent, if any, credit hours can be transferred.

GRIEVANCES I understand any grievances not resolved at the institutional level can be escalated to the Tennessee Higher Education Commission. I further understand that any person claiming damage or loss as a result of any act or practice by this institution that is violation of Title 49, Chapter 7, Part 20 or Rule Chapter 1520-01-02 may file a complaint with the Tennessee Higher Education Commission, Division of Postsecondary State Authorization (DPSA). DPSA’s address is 404 James Robertson Parkway, Parkway Towers Suite 1900, Nashville, TN 37243 and its telephone number is (615) 741-5293.

RELEASE OF INFORMATION In order to obtain information about my background, I give permission for Comprehensive Health Academy of Tennessee, LLC (CHAT) and its representatives to contact previous employers, schools and other agencies. I further give consent to Comprehensive Health Academy of Tennessee, LLC (CHAT) to perform a criminal background check. Furthermore, Comprehensive Health Academy of Tennessee, LLC (CHAT) has my permission to release my information, including but not limited to, grades, attendance records, and background check to potential employers and to sponsoring agencies or parties. I hold Comprehensive Health Academy of Tennessee, LLC (CHAT) harmless from liability with the obtaining the release of information. I certify that all information I have given is true. I understand that providing false information is grounds for termination from the program.

 HOLD HARMLESS I agree to indemnify and hold harmless Comprehensive Health Academy of Tennessee, LLC (CHAT) its employees, agents, sponsors, and externship representatives from any and all actions, causes of actions or claims of any kind or nature during my participation in activities in the classroom, skills lab, clinical setting, externship or other activities. I give consent for my photograph to be taken and used for promotional purposes for the school. I agree that I am in such physical condition as to allow me to participate fully in activities of the program. I agree to notify the institution of any disability I may have that falls under the American Disability Act and requires reasonable accommodations and/or assistance with evacuation in an emergency.

 PROGRAM DATA Withdrawal, completion, and placement data as calculated by THEC is not available at this time.  This program is new. Placement and withdrawal information will be provided by THEC after the institution has been operational for one year and following the institution’s reauthorization.

Signature

Do you agree to the terms of this agreement?

Yes No

By selecting yes the prospective student acknowledges that he/she has read this application, understands the terms and conditions, and agrees to the conditions outlined in this agreement. The student also agrees to comply with all school policies as outlined in the institutional catalog. The student certifies that all the information provided on this form is true. The student further understands their right to receive an exact signed copy of this agreement from the institution whom is obligated to provide an exact signed copy.

I certify, under penalty of perjury under the laws of Tennessee, that the foregoing is true and correct

Name (acting as e-signature)

Date

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Comprehensive Health Academy of Tennessee, LLC is authorized by the Tennessee Higher Education Commission.  This authorization must be renewed each year and is based on an evaluation of minimum standards concerning the quality of education, ethical business practices, and fiscal responsibility.