Nurse Assistant Registration Form

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Name *

Address *

Phone Number *

Email Address *

Date of Birth *

YYYY

Do you have a high school diploma or GED? If a student needs to test the ATB Exam due to not having the high school education requirements, you need to schedule with First Lady Permenente records department as soon as possible before SCOE provides acceptance into the program. *

Yes

Are you a high school senior who will have their diploma at the end of this school year? *

Yes

Are you currently enrolled in the Come Back Kids Program or did you receive your high school diploma from the Come Back Kids Program? *

Yes

Are you currently enrolled in Project YES? *

Yes

Do you receive CalFresh, CalWORKs or cash aid? * *

Yes

Are you a citizen of the United States? *

Yes

Do you speak any other languages besides English? *

Do you foresee any circumstances that may interfere with your ability to complete the course? *

Please note that this course will require a drug test prior to the start of class in order to work in the hospitals or doctor’s offices. Students must also complete a physical exam, provide Immunization records, provide records of a TB test, and a back ground check will be conducted on mybackgroundcheck.com. *

I understand that I will be required to provide documentation for all of these requirements.

I certify that my answers are true and complete to the best of my knowledge. If this application leads to enrollment, then I understand that false or misleading information in my application or interview may result in my release from the program. *

Check this box if you agree

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