Community-Based Residential Facility (CBRF) Training Registration Form

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Thank you for choosing Core Care Healthcare Training Center, LLC. for your healthcare training needs. We are excited to have you join our class! Please complete the registration form completely and submit your form.
We will be in contact via email to complete the registration process, and to discuss payment options.

Payment accepted:
1. ONLINE SQUARE PAYMENT INVOICE -CREDIT OR DEBIT CARD (VISA, MASTER CARD, AMERICAN EXPRESS) ONLINE VIA PAYMENT OF EMAILED INVOICE
2. CASH PAYMENT (IN FULL)- 7 BUSINESS DAYS PRIOR TO START OF TRAINING
3. MONEY ORDER OR CASHIER'S CHECK PAYABLE TO CORECARE HEALTHCARE TRAINING CENTER, LLC.

************NO CHECKS**************

Please Note: Classes are are offered weekly Monday-Friday (A.M.) Weekend classes are offered twice monthly. If you are are interested in group staff training, or have questions regarding class schedules please contact us via phone or email.

Thank you.

Core Care Healthcare Training Center, LLC.

NEW LOCATION!!!

8217 W. Becher Street
West Allis, WI.
Phone: 414-458-1661
Email: corecarecbrftraining@gmail.com
Website: www.corecarecbrftraining.com

Email *

Today's Date *

YYYY

Student Name (First/ Last) -Please list full name and check spelling for state registry purposes. *

Date of Birth *

YYYY

Address, City, State, Zip *

Phone Number *

Basic Skills Screening Tool (Check All That Apply) *

I am 18+ years

I have a High School Diploma, GED, or HSED

I can pass a caregiver background check.

I can follow basic written instruction and diagrams with no help or just a little assistance.

I can add, subtract, multiply, and divide with whole numbers up to 3 digits.

I speak and read English well enough to gain employment and keep employment.

I require special learning accommodations (ex. literacy services, visually/hearing impaired).

I have worked with clients with developmental or physical disabilities before.

I am interested in additional training with Core Care Healthcare Training Ctr. LLC. (CPR, CNA)

I speak a second language, and may need an interpreter.

Other:

Required

Name of Employer or Referral Agency (If your training is through your employer, please list point of contact Name, Address, Phone Number, or Email Address if available) List N/A if No. *

What date are you interested in starting training? *

YYYY

How would you like to complete your training? Please note: Medication Administration is a two part training. This course can be completed hybrid (virtual and Part 2 in person). If opting for virtual medication training, participants MUST have a valid verifiable testing proctor available for skills demonstration portion before testing virtually. *

Virtual

In-Person

Medication Administration (Hybrid)

CBRF Training (Weekday Mornings/ Weekend Saturday/Sunday start times may vary) Please contact for group rates for staff training. *

CBRF Registry (4) All Components $575+$20 Registry Fee+tax. Medication Administration, Standard Precautions, Fire Safety, First Aid & Choking

C.E.U- Continuing Education Units $395 + tax per person (3 Subjects)

Medication Administration $300+$20 Registry Fee + tax Part 1&2 (14 Hours)

Standard Precautions $175+$20 Registry Fee + tax (2 Hours)

Fire Safety $195+$20 Registry Fee + tax(5 Hours)

First Aid & Choking $195+$20 Registry Fee + tax (4 Hours)

Client Group/ Challenging Behaviors $175

Dietary Needs & Meal Planning $175

Residents Rights $175

Needs Assessment & ISP Planning $175

Understanding Diabetes $175

Manager's Training -$425

Staff Training Group Rate- TBD (Please Contact)

Other:

Required

Additional Training & Workshops (Weekends Only Saturday/Sunday) Please contact for Weekday Training *

Manager's Training -$375

Career Readiness Coaching & Workshops (Adults) - $200 Includes: Interview Coaching/ Employer Research (Ex. Mock Interview & Tips) Resume Development or Revision Services and Current Job Leads (Interview outcome/Job placement is based on employers needs and is NOT guarantied by CCHTC).

Career Readiness Coaching & Workshops for Teens (Ages 14-18 yrs) $100 per youth - Includes: Presentation on Career Exploration, Applications , Interview Coaching (Ex. Mock Interview & Tips) Resume Development/ Revision Services /Current Job Leads (Interview outcome/Job placement is based on employers needs and is NOT guarantied by CCHTC).

N/A

Required

Registration for classes require FULL payment to hold a seat for training. CCHTC is a service based business, therefor instructors are compensated for class prep time and materials. SPECIAL NOTE: CLASSES HAVE BEEN ADJUSTED DUE TO THE MOST RECENT COVID-19 PANDEMIC. YOUR SAFETY IS OUR PRIORTY. 1.Students are not required to bring or wear a mask during class, but may do so. 2.All training material and PPE will be provided for class and skills portion of training. 3. Classes of 10 students or less will be held at Core Care Healthcare Training Center's location. If your facility permits space for more than 10 students to be trained while adhering to CDC's social distancing recommendations, training must be approved by CCHTC's Director of Instruction. Please agree with terms below: *

I agree that no seat will be held for training without a completed registration form and full payment before training.

I agree if I am unable to attend my scheduled training date, I must contact CCHTC at least 3 business days prior to training to reschedule.

I agree payment for classes are non-refundable. Exceptions maybe made only by CCHTC's Instructors.

I agree that at times class schedules and locations may change. Instructors will notify students if this should happen. Payment will be honored at instructor's discretion.

I agree in the result of inclement weather, conflict of parties, or unforeseen emergencies instructors reserve the right to cancel classes at any time.

I confirm that I DO NOT currently have symptoms of illness (masks are not mandatory).

I agree that if I become ill in anyway, I will contact my instructor immediately before class, and WILL NOT show up to class.

Required

eSignature Agreement- By purchasing a service and reviewing the above terms, I agree to all statements and terms. I acknowledge by typing my name electronically, I have read and agreed to the polices and terms listed above and I am bound to the outlined contract with Core Care Healthcare Training Center, LLC. Core Care has the right to amend and or terminate services/ contract agreement at anytime. *

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