Application Form

SERENITY NURSE AIDE ACADEMY
6636 E. WT HARRIS BLVD. SUITE G & H
CHARLOTTE, NC 28215
PHONE : 704-567-9199        FAX : 704-567-4600
www.serenitynurseaide.com
APPLICATION
NAME :
ADDRESS :
CITY :
DOB :
STATE :
SS# :
Home Phone :
Alternate No :
Cell :
Emergency# :
Email :
Are you over 18 years old
Yes No
Have you ever been convicted by any government agency of child, patient resident or elderly abuse?
Yes
No if yes, please explain:
Are you being sponsored by a Medical certified facility? Yes No
If yes, you are not responsible for any costs associated with traning including the cost of textbooks and/or supplies
SPONSOR'S INFORMATION
Name of facility :
Address :
Phone number :
Contact person :
EDUCATION
SCHOOL NAME AND ADDRESS
Start Mo/Yr
End Date Mo/Yr
Did You Graduted?
Degree
COLLEGE UNIVERSITY
SCHOOL NAME AND ADDRESS
Start Mo/Yr
End Date Mo/Yr
Did You Graduted?
Degree
OTHER CERTIFICATIONS
Employment History (Most Recent Employment First)
Employer Name and Address
Start Date Mo/Yr
End Date Mo/Yr
Position Held
CPR Certified ? Yes No
Who Referred You to us ?
Please Check Course You Are Applying for:       Please Refer to "About Us" for the requierments and schedule to select your date
NA |
NA ||
NA | Refresh Course
Phlebotomy
CPR
Medication Aide
Med Tech
Medication Aide For Group Homes
*****$25.00(Twenty_Five dollor) application fee required non-refundable
I certify that the information provided in this applicatioun is true and complete to the best of my knowledge
i agree that if i misrepresent my self or omit any relevant information or provide false answer,
serenity nurse aids academy will disqualify me or discharge me from the program without refund.
(** If you have been convicted of a felony you can not enroll in Serenity Nurse Academy***)
Signature :
Date :