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CNA Class Pre-Registration Form
Please complete the following questions and click SUBMIT on the bottom of the page when you are done. This form will tell us if you are interested in the CNA class.
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* Indicates required question
Last Name (as it appears on your ID)
*
Your answer
First Name (as it appears on your ID)
*
Your answer
Nickname (Name you would like to be called, if different from first name)
Your answer
Street #, Street name, Apt. #
*
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
Cell Phone Number
*
Your answer
Email Address
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Do you want to take the CNA class this fall 2023
?
*
Yes
No
Are you interested in being employed as a CNA in the State of Connecticut?
*
Yes
No
Do you have transportation to Manchester Community College located in Manchester, CT?
*
Yes
No
Do you have transportation to a long-term care facility in South Windsor?
*
Yes
No
Do you have transportation to Ellington Volunteer Ambulance Corp. in Ellington, CT?
*
Yes
No
Do you have a computer/smartphone/tablet to use Zoom for the remote learning days of the CNA class?
*
Yes
No
Are you eligible to work in the United States?
*
Yes
No
Are you fully vaccinated against COVID-19, and willing to provide proof of vaccination?
*
Yes
No
Do you have a primary care physician?
*
Yes
No
I do not have one, but I will get a primary care physician
I do not want a primary care physician
Please introduce yourself, telling us who you are, what your interests are, and where you are from.
*
Your answer
Please describe why you are interested in taking the CNA class.
*
Your answer
Submit
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