Certified Nursing Assistant Course Application (Page 5 of 6) in pdf

Certified Nursing Assistant Course Application Page 5

PART D

Please read and sign.

I wish to be considered as an applicant for the Certified Nursing Assistant Course. I have

provided proof of educational transcripts to you. If accepted, I agree to abide by the rules and

regulations of the program. I understand my references may be checked. A State Bureau of

Identification (SBI) check will be initiated by this application process. The results of this SBI

check will be forwarded to the State of Maine CNA registry upon successful completion of this

course. My signature below gives MMC permission to conduct a SBI check. Failure to furnish

all information on past education, past employment, and personal background may constitute

adequate reason for disqualification of my application or subsequent dismissal. Falsification of

information of any application is reason for dismissal.

Applicant Signature:

Date:

FOR PROSPECTIVE CERTIFIED NURSE ASSISTANT STUDENTS

If you are considering a career as a Certified Nurse Assistant, you should be aware that during

the course of your training and subsequent employment, you are likely to be working in

situations where exposure to infectious disease is possible. This is an occupational risk for all

health care workers and persons should not become health care workers unless they recognize

and accept this risk.

Proper training and strict adherence to well-established infection control guidelines, however,

can reduce this risk to a minimum. Thorough training in infection control procedures will be an

important part of your Certified Nurse Assistant Training Program.

I have read and understand the above statement.

Applicant Signature:

Date:

Application for CNA Program

Revision: 9/2013

Page 5 of 6

Certified Nursing Assistant Course Application Page 5