Nurse Aide Training. Enrollment Agreement

Transcription

1 Applicant: Nurse Aide Training Enrollment Agreement Please fill out and mail back (or drop off) these signed forms plus your check in the amount of $ for your registration fee. This is to reserve your placement in the class. There are only 12 seats available per class. This program requires a scheduled interview before you can be accepted as a student into the ECG Technician Program. Please read this agreement before you sign it. After you sign and Kaua i Health Career Training accepts your application, you will be bound by the terms of this agreement. I agree to release and hold harmless the health care facility which provides my clinical experience, its employees and clinics and the Kaua i Health Career Training Center, for any misconduct or accidents that occur as a result of my participation in Kaua i Health Career Training Nurse Aide Training Program I understand the course policies as outlined in this packet and certify that all statements I have made on this application are true and complete. ATTENTION: False statements are subject to action that could lead to dismissal from this program. PLEASE NOTE: : Prior to your interview, at the discretion of thenurse Aide Training Program staff, a candidate may reschedule ONE TIME. Request to reschedule must be made at least 14 days to before class start date. After your interview process and acceptance into thenurse Aide Training Program, NO REFUNDS will be issued. Applicant Signature: Date: Accepted By: Date: Course: Tuition: Registration: Books: NCCT Tests: Total Cost: Nurse Aide Training $ $ $45.00 $ $1, Ask About Our Payment Plans XX% Discount on Full Payment Price can change with out notice OFFICE USE ONLY: Application Fee Paid: $ Invoice #: Date: Balance: Tuition Payments Paid: : $ Invoice #: Date: Balance: Total Payment: $ Invoice #: Date:

2 Nurse Aide Training Application Form Name: Sex: M F Last First Middle Social Security Number.: - - Date of Birth: Questionnaire: 1. How did you hear about this course? 2. Have you had any kind of experience in care giving/assisting with others physical or psycho-social needs (i.e. elderly, children, disabled or people with illness)? [ ] Yes [ ] No If yes, please describe the level and length of the care you provided. Please include experiences you have had as a volunteer, with your family and/or employment. 3. Have you taken any science or health care related course in school or have you had prior training in the medical field? [ ] Yes [ ] No If yes, please list the course(s)/training you have had: 4. Why do you wish to take this course? 5. What are your long-range goals? IN FIVE YEARS, I WANT TO BE: IN TEN YEARS, I WANT TO BE: 6. What do you feel you have to offer to the health care profession?

3 Nurse Aide Training Information Form Name: Sex: M F Date of Birth: Address:

4 CONFIDENTIAL AGREEMENT for the Nurse Aide Training Program The medical information obtained in the course of our duties is particularly sensitive, because of its nature. It concerns personal and private aspects of our patients lives. Given the sensitive nature of this information, it is Kaua i Health Career Training s policy to treat all patient information with the utmost discretion and confidentiality and to prohibit improper release in accordance with the confidentiality requirements of state and federal laws and regulations. Kaua i Health Career Training will expect students to adhere to the Federal Health Insurance Portability And Accountability Act (HIPAA) standards regarding control of the use of health information for patients. The school requires that individual identifiable medical information be kept confidential. I understand that while as a Student given access to information on the clinical offices that I may go; to I may receive, directly or indirectly, information which is confidential, sensitive or privileged involving items such as: 1) Patient claimed histories, patient diagnosis/treatment, medical records, identification numbers and other personal information. 2) Patient accounting, billing and other routine reports which clinical offices are required by law, regulations or company policy to maintain. 3) Materials, techniques and documents were curding operating systems, procedures or organizational status. 4) Strategic and tactical planning. 5) Information from patients, customers and vendors. 6) Personnel information, payroll and company reports. I agree not to request information, which is confidential, sensitive or privileged unless such information is necessary to perform the job to which I have been assigned. I also agree not to use or disclose any confidential, sensitive or privileged information. I will refer questionable cases to my teacher for instructions. I understand and agree that I am required to continue to safeguard such confidentiality. By signing below, I forthwith understand that the obligation above is a condition for being in the class. Any breach of this agreement can result in my immediate removal from this class with no refund and Kaua i Health Career Training may pursue legal action against me. Print Name: Signature: Date:

5 Student Information (please print) Physical Examination Form for the Nurse Aide Training Program Name: Sex: M F Date of Birth: Have you had a serious illness injury or surgery are you currently being treated for any illness? If yes, explain: TO BE COMPLETED BY EXAMINING PHYSICIAN Current complaints or disabilities pertinent to the student s education in the Nurses Aide Training Program: Medications Used (include over-the-counter and prescription. use back if necessary) NAME: REASON: FREQUENCY: Significant Medical History (major illness, accidents, deformities, surgeries, back problems, hepatitis etc.) Examination Comments and Findings REQUIRED TUBERCULOSIS SCREENING P.P.D. (within 1 year) Date: Results: Chest X (if P.P.D. position) Date: Results: The above named had neither communicable or disabling disease nor any health condition that would create a hazard to themselves, fellow classmates, visitors or patients at this time. She/he is able to perform the physical activities required for the program for which the individual is applying. Medical Examiner: Phone: Address: City: State: Zip: Signature: Date: Physician (M.D.) / Physician Assistant / Nurse Practitioner I understand and give permission to release a copy of this form to the participating clinical facility Student Signature: Date: