ENROLLMENT APPLICATION

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1 ENROLLMENT APPLICATION Nurse Aide Program Last Name: First Name MI: Address: City: State: Zip: Phone: Emergency Contact Are you 18 or older [ ] yes [ ] No Social Security Number: Are you currently employed? [ ] yes [ ] No if yes, work phone #:

2 Institute EDUCATION School (high School College) How many Years Degree/ Diploma Major Other Trainings Certificate Earned Date REFERENCES Please provide names of three people you have known for at least one year (Must be non-relatives) Name Day Phone # Relationship Year known I hereby, authorize the release of any information regarding current/past employment and education to Institute. I certify that none of the information was falsified. Signature: Date:

3 Institute CANCELLATION AND REFUNDS 1. Student applicants who cancel before the first day of class will be charge $ nonrefundable fee to cover the cost of enrollment processing. 2. Student applicants that are enrolled in a class who cancel after attending the first and second day of class will be entitled to 50% of the tuition. 3. Student who withdraws or is terminated after three (3) classroom sessions may not receive any refunds. Applicant Printed Signature: Date: Applicant Signature: Institute Representative: Signature: Date:

4 Institute CRIMINAL DISCLOSURE AND AGREEMENT I, understand and as I have been advised by Gee s Career Training Institute that the law prohibit healthcare agencies from hiring any one convicted of crimes unless as proved in the case of misdemeanor crimes. Misdemeanor crime not involving abuse or neglect or moral turpitude may be hired provided five years have lapsed since the conviction. I am of sound mind and good judgment while making this decision to educate my self about the healthcare profession by taking the Nurse Aide Program. I release Institute of any and all liabilities. I agree and promise Gee s Career Training Institute that I will not seek employment in the healthcare industry while this misdemeanor is still pending on criminal records. Signature: Date: Institute Representative: Title: Date:

5 Institute Complaint/Grievance Procedure If you have nay problem while training at GCTI, please follow the process as outline below: first discuss the issue with your instructor. The instructor will make every effort to resolve the issue, however, if you are not completely satisfied with the result, you should schedule an appointment with the school Administrator, Gifty Kotey R.N., she will make every effort to resolve your problem. She will also document every effort made to resolve the issue or remedy the situation. If the problem cannot be resolved by the school administrator, you can then contact the Department of Education, P.O. Box 2120, Richmond VA Graduation Upon successful completion, of the program, you will receive a certificate form GCTI. Your certification meets the Department of Health approved standard for Nurse Aide. Absences and Tardiness You are responsible for notifying the instructor in advance about any absence or tardiness from class. Any un-excused absence or tardiness may be ground for termination or you may be assessed additional fee for a private tutoring to meet the program requirements. Termination or Dismissal Policy GCTI may dismiss a student for any of the following reason: 1. Frequent tardiness or absence due to lack of interest for the program. 2. Failure to maintain academic standard 3. Disorderly conduct either verbally or physically 4. Alcoholism or drug abuse 5. Sexual Harassment 6. Dishonesty etc GCTI reserves the right to terminate a student when such action is to the best interest of the class. Student Record All student record will be kept confidential and made available only to the student or any authorizes person as stated only in writing. Student will be allowed to review their records upon writing request to the administrator. Any deletions or additions to the student s record must be in writing and must be approved by the administrator. All and any request by the student must be in

6 writing and forwarded to the administrator for consideration and approval. Institute Statement of Non- Discrimination Student enrollment at Institute is based on students meeting all school requirements for admission. GCTI make all its business and admission decisions without regards to race, color, sex, age, ethnic or national origin, sexual preference or orientation, disability, veteran or marital status or any other characteristic protected by law. Program Purpose To brain and teach qualified person to provide safe, Customer- focused high quality, direct care and services to long term care residents under the supervision of licensed Professionals. Students are expected to abide by GCTI policies and procedures. Any student who does not uphold the school standards will not graduate and will not receive any refund. Students are expected to demonstrate responsible and acceptable behavior while in training. GCTI expects students to: 1. Arrive to class on time and prepare to learn. 2. Ask question or voice any concern regarding the program 3. Dress appropriately and professionally 4. Conduct him/her elf in a respectable and professional manner 5. Turn in all class assignments 6. Participate in class activities e.g. vital sign, bed making etc. 7. Participate in class activities e.g. vital sign, bed making etc. Achieve a grade of 80% of higher on all quiz and final exam. Fees and Payment Policy Program fee is paid in advance. Fee includes books, uniform, CPR/FA. Payment is made payable to GCTI, by check or money order. All cash payment will be given a receipt. Credit cards are accepted. You may be allowed to attend classes on promissory note after a down payment of least $ of the tuition. However, full payment must be made before the end of the course. Any balance due on the course will be assessed a 10% late fee and must be paid in full before certificate can be issued to student. Dress Code No offensive clothing that exposes too much body parts or extremely tight or short. Clinical

7 uniform such as scrubs can be worn during classroom lecture. Employment Assistance It is the responsibility of each student to secure employment upon successful completion of the program. We will provide employment assistance upon graduation. However, YOU HAVE THE CHOICE TO WIRK WITH ANY employment agencies or organizations. Institute Woodbridge, VA Phone (703) Fax (703) TO ALL STUDENTS This Background check is done on all students to assure our clinical site that our students are safe to practice as students. You do not need to fill out the form; it will be done by computer submission. Attached is a sample of the computer submitted form. Thank you. School Administrator.

8 Institute REQUIREMENTS COMPLETED IN ORDER TO GO TO CLINICALS: ALL TUITION PAID IN FULL PPD/CHEST XRAY DONE AND COPY OF DOCUMENTATION IN STUDENT FILE PERSONAL MEDICAL MALPRACTICE INSURANCE WITH COPY OF CERTIFICATE IN STUDENT FILE 80% CLASSROOM WORK GRADE AT LEAST 80 HOURS OF CLASSROOM ATTENDANCE AND WORK TO INCLUDE CPR CERTIFICATION SCHOOL UNIFORM, MANUAL BLOODPRESSURE CUFF, SEPARATE STETHOSCOPE; WATCH WITH SECOND HAND, BLACK PEN, SMALL POCKET NOTE BOOK REQUIREMENTS COMPLETED IN ORDER TO GRADUATE: ALL ABOVE ITEMS PLUS: SATISFACTORY CLINCAL GRADE 80% AND ABOVE 40 HOURS OF CLINICAL ATTENDANCE I AGREE TO THE ABOVE REQUIREMENTS FOR THE COURSE AND I UNDERSTAND IF REQUIREMENTS ARE NOT FULFILLED AS STATED ABOVE I MAY NOT ATTEND CLINICALS AND/ OR GRADUATATE UNTIL THEY ARE FULFILLED. CLINICALS MISSED FOR NON-COMPLIANCE WILL BE REQUIRED TO BE MADE UP WITH THE NEXT CLINICAL THAT FORMS AND/ OR AS SPACE PERMITS. NAME PRINTED: SIGNATURE:

9 DATE: / / Institute PAYMENT AGREEMENT I, (PLEASE PRINT NAME ABOVE) (HERE AFTER REFERRED TO AS STUDENT) DO HEREBY AGREE TO THE FOLLOWING PAYMENT AGREEMENT FOR THE NURSE AIDE PROGRAM AT GEE S CAREER TRAINING INSTITUTE: TOTAL PROGRAM TUITION $1,450 DOWN PAYMENT (DATE / / ) BALANCE DUE $ $ PAYMENT SCHEDULE: (FOUR PAYMENT OF $ EACH) DUE DATE: AMT. DUE $ DUE DATE: AMT. DUE $ DUE DATE: AMT. DUE $ DUE DATE: AMT. DUE $ THE BALANCE DUE MAY BE PAID IN FULL AT ANY TIME PRIOR TO DUE DATES. PAYMENTS MUST BE MADE ON TIME ACCORDING TO THE AGREED SCHEDULE OR STUDENT WILL NOT BE ALLOWED TO CONTINUE IN CLASS. THE BALANCE DUE MUST BE PAID IN FULL BEFORE STUDENT WILL BE ADMITTED TO CLINICALS AND /OR BEFORE STUDENT WILL RECIEVE FINAL GRADE FOR THE CLASSROOM SECTION OF COURSE. STUDENT WILL NOT BE ABLE TO SIT FOR THE VIRGINIA STATE NURSING ASSISTANT TEST UNTIL ALL FEES DUE

10 TO GCTI ARE PAID. SIGNATURE: DATE: / /

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