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Cbarnes@helpmecareedu.com

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Job Placement
Let Us Assist You
Contact us
About Us

Nursing Assistant

Nursing Assistant Application

Full Name:

Address:

State:

Phone:

Email:

Date Of Birth:

Social Security No.:

Gender

Male Female Other

Type of Program:

CPR Home Health Aide Certified Nursing Assistant Program

Education:

Did You Graduate?

Yes No

Diploma GED

Address:

College:

Did you Graduate?

YES NO

Degree

Background Information: Are You A citizen of the United States?

Yes No

If No, are you authorized to work in the U.S.?

Yes No

Have You Ever Been Convicted of a Felony?

Yes No

If yes, explain:

Have you convicted at any time, of any crime, other than a minor traffic-related offense? You do not need to disclose any marijuana-related offenses regarding activities legalized under state statuteHEALTH SAFETY STATUTE Title (57 of code 768.01)

Yes No

If yes, list conviction:

Court of conviction:

Has any licensing agency, employer, or disciplinary authority taken adverse action (denied, annulled, canceled, placed on conditional registry, etc.) against you?

Are you employed?

Yes No

If yes, please list place of employment

Please list 3 personal references:

Do you have children?

Yes (with custody) No

If children are under the age of 18, do you receive government benefits (SNAP, Medical, Cash Assistance)

Are you an active member of the United States Military or a U.S. Veteran

Yes No

If yes, list branch and years enlisted:

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

Sign

Date

Thank You

Ready to begin a new, exciting career?

HEALTHCARE PROGRAMS

Nursing Assistant

Nursing Assistant

STUDENT RESOURCES

Student Grievance Procedure
Financial Aid
Program FAQs
Cancellation and Refund Policy
Student Handbook/ Catalog
Student Handbook

Student Grievance Procedure
Financial Aid
Program FAQs
Cancellation and Refund Policy
Student Handbook/ Catalog
Student Handbook

Schedule and Information

2025/2025 Schedule

2025/2025 Schedule

844.444.7493 Ext #3
33 Sexton St. Struthers OH 44471

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Nursing Assistant Application

Thank You

Ready to begin a new, exciting career?

HEALTHCARE PROGRAMS

STUDENT RESOURCES

Schedule and Information

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