January 2021 CNA enrollment form | American Safety Programs and Training

Please register below for the January 4th 2021 CNA Class

You will receive information and further instructions by email by December 23rd 2021.

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email *

Confirm Email

Day or night class

Free baby sitting service needed? *

Ripta bus pass needed for school? *

Mandatory Compliance *

I have no felony convictions on my BCI.

A hard copy of your BCI will be due once the State BCI office is open. If you have a felony conviction on your BCI, you could be charged for the cost of the course and disqualified.

Enrollment Terms and Conditions *

I Agree

You are applying for State funded CNA training. By clicking the box above you agree that you will be present for all required classes. You are also agreeing that you will work as a CNA upon licensure for a minimum of 1 year at any facility of your choice. You must disclose your employer, rate, benefits and weekly hours offered for stated auditing. This is a requirement to ensure we are giving you the best opportunities possible. Failure to work as a CNA shall require reimbursement (from student) for all cost incurred to educate you in the CNA program at American Safety Programs and Training INC. You must have a BCI that that meets minimum requirements to enter the CNA program and must maintain a clear BCI during your education. You are also agreeing that you will be subject to pre-employment drug screening. Failure to pass drug screening could result in reimbursement for program.

Signature *

Use your mouse, track pad or finger to sign your name.

Date / Time *

Date

Time

Phone