Geriatric Aide Training Program For Registry Listing Community College Approval Application Form - N.c. Department Of Health And Human Services Page 2

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Clinical Sites
Clinical Site #1
Name: ________________________________________________________________________________
Address: ______________________________________________________________________________
Area Code/Telephone Number: ____________________________________________________________
Clinical Site #2
Name: ________________________________________________________________________________
Address: ______________________________________________________________________________
Area Code/Telephone Number: ____________________________________________________________
Clinical Site #3
Name: ________________________________________________________________________________
Address: ______________________________________________________________________________
Area Code/Telephone Number: ____________________________________________________________
Attach an additional sheet with the above information if you have more than three (3) clinical sites.
FACULTY: (
Faculty Approval Request forms can be found at )
Program Coordinator: _________________________________
RN Certificate Number _____________
Previously approved as NAI program coordinator OR
Faculty approval form is attached.
Will the PC serve as an instructor?
yes
no
Instructor: ______________________________________
RN Certificate Number ____________
Previously approved as NAI instructor
OR
Faculty approval form is attached.
Instructor: ______________________________________
RN Certificate Number ____________
Previously approved as NAI instructor
OR
Faculty approval form is attached.
Instructor: ______________________________________
RN Certificate Number ____________
Previously approved as NAI instructor
OR
Faculty approval form is attached.
COMPLETING THE APPLICATION PROCESS
Please e-mail (pdf only) your application to
brenda.sanders@dhhs.nc.gov
or fax to 919-733-9764.
Please contact Ms. Sanders at (919) 855-3970 if you need further information.
FOR OFFICE USE ONLY - DO NOT WRITE IN THIS BOX
Program # Assigned
______ Continuing Education
_______ Curriculum
_____________________
2
DHHS/DHSR-4509 (Rev. 3-2015)

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