Richmond, Virginia. Nurse Assistant Training Program Application ADMISSION REQUIREMENTS CLASS INFORMATION

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1 Richmond, Virginia Nurse Assistant Training Program Application The American Red Cross Nurse Assistant Training Program exceeds the Virginia Board of Nursing s requirements for Nurse Assistant Training in Virginia. The expectation of excellence is high in this fast-paced and focused program. Your instructors are highly-experienced Registered and Licensed Practical nurses dedicated and committed to your success. The course is 130-hours long including 40 hours of clinical experience. Through lecture, video, role-playing, and hands-on laboratory and clinical practice, you learn procedural skills such as bathing, dressing, positioning, and vital signs. You also learn key communication techniques to provide compassionate care for people within the health care system. Our classroom/lab is equipped with hospital beds and all necessary medical equipment to practice skills. After graduation, you are eligible to sit for the Virginia Certified Nurse Aide (CNA) exam. ADMISSION REQUIREMENTS At least 18 years of age US citizenship or current Permanent Residence (Green) Card A High School Diploma or equivalent Basic computer skills and ready and reliable access to an internet capable computer with printer Obtain proof of negative Tuberculosis and Measles-Mumps-Rubella (MMR) and optional Hepatitis B vaccination prior to Orientation Day. See your healthcare provider, community clinic or urgent care center for more information. Must be provided with application or on Orientation Day. Clear background check of no felony or misdemeanor convictions (Including DUI/drug.) See next page. Note: The classroom, lab and clinical sessions require the ability to learn in a fast-paced academic environment coupled with strenuous physical activity. If you have any conditions that could affect your ability to participate including learning disability, pregnancy, chronic condition or an injury, please attach written permission from your physician or clinician to this application. Applicable conditions revealed after enrollment without permission to participate will be grounds for non-refundable dismissal. CLASS INFORMATION Day Class Class/Lab Time: Monday thru Friday 9:00 am 3:00 pm Day Clinical Rotation Time/Date: Monday thru Friday 6:45 am 3:15 pm Night/Saturday Class Class/Lab Time: Tuesday/Wednesday/Thursday 6:00 pm 10:00 pm Saturday 9:00 am -3:00 pm Clinical Rotation Time/Date: Saturday 6:45 am 3:15 pm Classroom Location: American Red Cross Building 420 East Cary Street Richmond, VA Clinical Location: McGuire Veterans Administration Medical Center 1201 Broad Rock Road Richmond, VA Office: Telephone: M-F 9:00-1:00 or [email protected] 1

2 BACKGROUND CHECKS/BARRIER CRIMES We conduct a full criminal background check of all eligible candidates. We will not allow persons with certain felony or misdemeanor charges and/or convictions to participate (including DUI/drug.) You must pass this check. Please complete the last page of this application (Background Check Disclosure and Authorization Form) and submit with your program application. Certain criminal convictions may prevent certification as a nursing assistant in Virginia, and/or prohibit employment in certain health care settings. Some criminal convictions, also known as Barrier Crimes will prohibit employment in nursing home facilities, home care organizations, hospice programs and assisted living facilities. Please refer to the link below for the, Joint Statement of the Department of Health and the Department of Health Professions on Impact of Criminal Convictions on Nursing Licensure or Certification and Employment in Virginia. For more information go to: EXPECTATIONS FOR YOUR SUCCESS Your Reading/Computer Skills: Many of your lesson plans, skills explanations, homework assignments and in-class assignments involve independent reading assignments (based on 8 th grade reading ability) and work on a computer. You are expected to have basic reading skills and ready and reliable access to an internet-capable computer/printer. Your Attendance: Because of the pace and focus of this course, you are expected to attend every clinical and classroom session and to be on time. In case of emergency or illness that requires that time be missed, discuss your situation with your instructor. A leave of absence and/or re-enrollment request may be submitted for consideration. Your Dress Code: For your health and safety and of those around you, adhering to the dress code is expected at all times. Classroom: Business casual Clinical Rotation: White scrub top with red scrub pants Clean white shoes with non-skid soles (not backless) Limit jewelry to a plain band and simple post earrings. No facial jewelry Nails trimmed not extending beyond tips of fingers. No colors or designs Hair must be pulled back and off your shoulders Stethoscope Watch with a second hand Pen and notebook. Identification Badge: American Red Cross, Nursing Assistant Training Program photo identification badges will be provided on the first day of class. Your photo identification must be worn daily to class and during your clinical rotation. Your Academic and Student Policy: You are expected to come prepared to class with all work assignments completed. The passing standard is 80% or above on all quizzes and the final exam. All skills listed in the student textbook will be performed with 100% accuracy. In the clinical setting you are expected to demonstrate respect, truthfulness, reliability, timeliness and good judgment in providing safe care to residents. Cheating is grounds for immediate dismissal from the program with forfeit of all fees. Your Medical History: The class is delivered in an accelerated and focused academic learning environment. The lab/clinical sessions require strenuous physical activity. If you have any conditions (including pregnancy, learning disability, preexisting/chronic injury/illness) that may impact your ability to safely and fully participate you must submit a physician s or clinician s release with no restrictions allowing your full participation. All information is kept confidential. Failure to Disclose This Prior To Acceptance Will Result In Non Refundable Dismissal. 2

3 REGISTRATION INFORMATION Please mail your application to: American Red Cross Nurse Assistant Training Program-Richmond P.O. Box 655 Richmond, VA ATTN: NATP Admissions Coordinator -Important: You will be sent an acknowledging receipt of your application. Submission of an application does not guarantee enrollment. - Incomplete applications will be rejected. Applicants will not be notified of incomplete applications. -Due to the large number of applications, please do not call/ to check on your application status. If you are selected for admission, a Red Cross staff member will contact you. Tuition: $1, Your Tuition Includes: All classroom, lab and clinical instruction All Textbooks and class/lab materials Red Cross CPR/AED Certification Stethoscope American Red Cross Photo ID Badge American Red Cross Nursing Assistant Pin and Certificate upon Graduation. -Full tuition is due 5 business days before Orientation Day Night/Sat. Class: Due 5 days before Day 1 of class. -To reserve (but not guarantee) a position in a class, submit your application with tuition paid in full. Indicate your preferred class date on the application next to Requested Class Start Date. After your application has been received and reviewed, you will be notified in two business days if you are accepted in the program on the date you selected. If you are accepted and your preferred date is full, you will be offered alternative dates. If those are not acceptable, you will be provided a full refund. -Cash and personal checks are not accepted. Please pay by Money Order/Cashier s Check/Credit Card (Visa/MasterCard Only). Make Payable to: American Red Cross Nurse Assistant Training Program- Richmond. Memo line: NATP Tuition. -To keep our administrative costs as low as possible the Red Cross does not offer payment plans. Financial Assistance Available: -Financial assistance with tuition may be available to qualified applicants. If you would like more information, please indicate that on your application or contact us at M-F 9:00-1:00 or [email protected] Attention Members of The Military and Families: -Wounded Warriors: Thanks to funding from the Wounded Warrior Project, t100% tuition and testing funding is available to qualified service members, their family or caregiver. Contact us at M- F9:00-1:00 or [email protected] for details. -Military spouses: This program is approved for 100% tuition and testing funding through My CAA, To check eligibility and for more information about My CAA call Please check eligibility prior to submitting your application. 3

4 Medical Education Program Registration Form ** Any sections left blank WILL DELAY program enrollment ** STUDENT INTEREST (check all that apply): Nurse Assistant EKG Technician Phlebotomy Technician Home Health Aide REQUIRED INFORMATION: Please complete with a pen and print First Name Last Name Names Previously Used Circle one: Male or Female Social Security #: Date of Birth: Address City State Zip County Address Home Phone ( ) Alternate/Cell Phone ( ) Language Spoken Secondary Language Yes No Do you have a learning disability? Yes or No If Yes, what type? Hearing Impaired: Yes or No Any Services Needed? Visually Impaired: Yes or No Any Services Needed? How did you hear about our program? Friend/Relative Past Graduate Website/Online Ad/Newspaper Community Agency/Case Worker Other: Please list name/organization/source where you heard about the program: EMERGENCY CONTACT: Name: Relationship: Emergency Telephone: ( ) Alternate Emergency Number: ( ) Are you a Wounded Warrior, family or professional caregiver of a Wounded Warrior? Yes No DEMOGRAPHIC INFORMATION: Race (Circle One): Caucasian African American Asian Hispanic Native American Other Marital Status (Circle One): Single Married Divorced Widowed Dependents: How many children do you have legal custody of? Income: Do you currently receive any of the following assistance? (Circle all that apply) Cash assistance [Welfare, TANF, OWF, etc.] Food Stamps WIC Child Care Public Housing Child Support SSI/Disability Alimony Worker s Compensation Medicaid/Medicare Unemployment What is your personal total annual [yearly] income? [Please count all sources of income including day care and food stamp benefits.] $0-$9,999 $10,000-$14,999 $15,000-$19,000 $20,000-$29,999 $30,000 and above EDUCATION: (Circle all that apply) GED High School Diploma Vocational Training Associate Degree Bachelor Degree Other Certification Programs/Post-HS programs Year receive: 4

5 WORK HISTORY: Employment: Are you currently employed? Yes or No, If Yes, where? City where employed: Start Date Full-time Part-time PRN/On-Call/Varies/Seasonal Have you previously ever worked as a Nursing Assistant/Home Health Aide or other Healthcare Professional? Yes or No If Yes, year and location: JOB SEARCH: (Information after Graduation) Where are you interested in working: Nursing Home/Long-Term Care Facility Home Care Hospital What shifts are you available to work? Mornings/Days Afternoon/Evenings Nights Weekends What type of transportation do you have? Car Bus/bus line accessible Relative/Friend Bike/Walk ESSAY: In the space provided below, tell us why you want to join our program and begin your new career (in 3-4 sentences): CRIMINAL RECORD: (See Background Check/Barrier Crimes on Page 2) HAVE YOU EVER BEEN CONVICTED OF A FELONY OR MISDEMEANOR? YES OR NO IF YES, PLEASE LIST THE DATE AND CHARGE & EXPLAIN HAS ANY HEALTH-RELATED LICENSING, CERTIFICATION OR DISIPLINARY AUTHORITY TAKEN ADVERSE ACTION (REVOKED, ANNULLED, CANCELLED, SUSPENDED, ETC.) AGAINST YOU? YES OR NO IF YES, INDICATE THE DATE OF CHARGE, TYPE LICENSE/CERTIFICATE NUMBER: I hereby acknowledge that my statements above are true and correct. I understand that false or inaccurate information will be basis for termination from the Red Cross program. I understand the Red Cross program attendance requirements and refund policy. If my background check indicated that I have been convicted of a disqualifying crime, I will be ineligible for employment as a caregiver in my state and not permitted to attend the Red Cross course. I authorize the American Red Cross to release this application information and my complete program student file to my potential employers and other organizations that may offer scholarships for promising program candidates. My complete Red Cross program file, including: grades, attendance records and all other course materials may be released to my funding source third party provider, caseworker or potential employer, if requested. Enrollee/Student Signature Date Note: Additional Background Check Authorization Signature Required on Next Page. AMERICAN RED CROSS OFFICE USE ONLY SABA# Date Processed Order # Amount Paid $ Offering ID Class Start Date 5

6 DISCLOSURE AND AUTHORIZATION [IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING AUTHORIZATION] DISCLOSURE REGARDING BACKGROUND INVESTIGATION American Red Cross Medical Education Programs ( ARC ) may obtain information about you for educational/future healthcare employment placement purposes from a third party consumer reporting agency. Thus, you may be the subject of a consumer report and/or an investigative consumer report which may include information about your character, general reputation, personal characteristics, and/or mode of living. These reports may contain information regarding your criminal history, social security verification or other background checks. You have the right, upon written request made within a reasonable time, to request whether a consumer report has been run about you, and disclosure of the nature and scope of any investigative consumer report and to request a copy of your report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for educational/future healthcare employment placement is an investigation conducted by Asurint, Compliance Department, P.O. Box 14730, Cleveland, OH 44145, (800) , another outside organization. The scope of this notice and authorization is allencompassing, however, allowing the Company to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and throughout the course of your educational/future healthcare employment placement to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report. ACKNOWLEDGMENT AND AUTHORIZATION I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of consumer reports and/or investigative consumer reports by ARC at any time after receipt of this authorization and throughout my educational/future healthcare employment placement, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Asurint, Compliance Department, P.O. Box 14730, Cleveland, OH 44145, (800) , another outside organization acting on behalf of ARC, and/or ARC itself. I agree that a facsimile ( fax ), electronic or photographic copy of this Authorization shall be as valid as the original. Print Name (First) (Middle) (Last) Other Former Name(s)/Alias Dates Used: Social Security Number: Date of Birth: Telephone Number(s): Current Address: (Street) (City) (Zip/State) Previous Address: (Street) (City) (Zip/State) Previous Address: (Street) (City) (Zip/State) *This information will be used for background screening purposes only. Applicant Signature: Date: Signature of Parent/Guardian: Date: (Required if applicant is a minor- under the age of 18) REV. 1/10/14 6