Quest Nursing Education Center 2135 Broadway, Oakland, CA P: (510) Enrollment Application

Transcription

1 STUDENT INFORMATION Enrollment Application Name: Address: Phone: Last First MI Other Name Used Number / Street City State Zip Daytime Evening Message DOB: SSN: - - POB: mm/dd/yyyy Place of Birth DL / ID Number: Height: Weight (lbs): Hair Color: Eye Color: Male: Female: Primary Language: Name of Primary Language English: if English only Have you ever been convicted of a crime other than a minor traffic violation? Yes No How did you find out about us? EMERGENCY CONTACT Name: Address: Phone Relationship: PREVIOUS EDUCATION High School: Dates Attended: Graduation Date: GED: From: mm/yyyy To: mm/yyyy mm/yyyy if GED only College: Graduation Date: Degree: Name of Institution mm/yyyy I certify under penalty of perjury that the above information provided by me the applicant is true and correct. I understand that falsifying any information is grounds for immediate dismissal without a refund. Name: Signature: Date: Print Name Here Quest Nursing Education Center 2135 Broadway Oakland, CA 94612

2 CERTIFIED NURSING ASSISTANT: Are you at least 16 years old? STUDENT ELIGIBILITY CHECKLIST: PLEASE FILL OUT FOR THE COURSE YOU ARE ENROLLING IN Are you legally able to work in the United States Are you in good physical and mental health* Do you have a Valid Social Security Number *Please note that admission into the program is contingent upon successfully passing a medical physical exam which includes a PPD Tuberculosis skin test and/or Chest X-ray indicating good health by a licensed physician or Nurse Practitioner. HOME HEALTH AIDE: Have you successfully completed a California State approved Nursing Assistant Program and Eligible for licensure as a Certified Nursing Assistant*: * Please note that certification as a Certified Home Health Aide is contingent upon successful certification as a Certified Nursing Assistant. IV THERAPY/BLOOD WITHDRAWAL (LVNs) Have you successfully completed a California State approved Vocational Nursing Program and are Eligible for licensure as a Licensed Vocational Nurse*: Please note that certification in IV therapy and Blood Withdrawal is contingent upon successful Licensure as a Licensed Vocational Nurse EMERGENCY MEDICAL TECHNICIAN (EMT) Are you at least 16 years old? Yes No Are you legally able to work in the United States Are you in good physical and mental health* Do you have a Valid Social Security Number Do you have a High School Diploma or GED equivalent *Please note that admission into the program is contingent upon successfully passing a medical physical exam. In addition The following immunizations are required: MMR Vaccination (Measles Mumps Rubella), Hepatitis B, TB Test- (Tuberculosis) and the test must be within the past 6 months before the class start date. If known to be PPD positive, must have a negative chest x-ray. FOR ALL APPLICANTS: Are you currently under investigation or have ever been arrested of an infraction, misdemeanor, or felony in California or any other state or place including entering a plea of nolo contendere or no contest and including any conviction which has been expunged (set aside) or records sealed.** **If you are currently under investigation or have ever been arrested of an infraction, misdemeanor, or felony in California or any other state or place including entering a plea of nolo contendere or no contest and including any conviction which has been expunged (set aside) or records sealed. You must disclose action(s). Falsifying this information may result in the inability to receive certification and Quest Nursing Education Center will NOT be liable for tuition and expenses paid if found ineligible for certification. I certify under penalty of perjury that the above information provided by me the applicant is true and correct. I understand that falsifying any information is grounds for immediate dismissal without a refund. Name: Signature: Date: Print Name Here Quest Nursing Education Center 2135 Broadway Oakland, CA 94612

3 TUITION BREAKDOWN- Please select payment plan and enclose applicable fees CNA PROGRAM TUITION BREAKDOWN $ 150 Application Fee $ 250 Deposit $ 150 Supplies $ 350 Tuition $ 25 Professional liability insurance Total Fees: $925 Payment Plan Option 1: To Register: Pay $150 (Includes Application Fee) Pay $750 Prior to class start date: Receive CPR FREE!!!* * Required Textbook for CPR not included in free course but may be purchased from Quest Nursing Education Center for $15. Payment Plan Option 1: To Register: Pay $150 (Includes Application Fee) First day of class: $375 (Also due is $25 insurance) Two weeks into class: $375 Full payment: ( Enclose $925) Payment Plan Option 1 : ( Enclose $150) Payment plan Option 2: ( Enclose $150) HHA TUITION: $350 IV THERAPY/BLOOD WITHDRAWAL TUITION: $350 EMT PROGRAM TUITION BREAKDOWN: $ 150 Application Fee $ 500 Deposit $ 250 Supplies $ 850 Tuition $ 25 Professional liability insurance Total Fees: $1775 Payment Plan Option: To Register: Pay $675 (Includes Application Fee, Deposit, and Insurance) First day of class: $350 Two weeks into class: $350 Last day of class: $400 Official Use Only Fee Status: AF PP PIF Dates/Amounts: / / / Reviewed By: Initials Quest Nursing Education Center 2135 Broadway Oakland, CA 94612

4 QUEST NURSING EDUCATION CENTER REFUND POLICY: All courses that cost $350 or less is not refundable. For courses above $350: The student has a right to a full refund of all charges less the amount of the application fee if he/she cancels this agreement at least 7 days prior to first day of instruction. Beyond 7 days to first day of instruction, the tuition deposit and the application fee becomes nonrefundable. In addition, the student may withdraw from a course once instruction has started and receive a pro rata refund minus the application fee, tuition deposit, and supplies cost, if the student has completed less than 60% of the instruction. Daily rate for tuition is calculated by total fees paid divided by number of days. No refund is available once 60% or more of the class has been completed. For example: if the student attended 2 days of a 20-day course and paid the application fee (150) and $750 tuition, the student would receive a refund of $310 (see example below). $950 Total fees Paid Minus $150 School application fee Minus $250 non-refundable tuition deposit Minus $150 Course supply Minus $90 ( 2 days received) ( $950/20 days) ($45/day) REFUND: $310 If the school cancels or discontinues a course, the school will make a full refund of all charges. Refunds will be paid within 30 days of cancellation or withdrawal. Students will be liable for any unpaid tuition fees that were accumulated by the student s attendance prior to withdrawal from the course. Any fees made towards attaining professional liability insurance for the student is non-refundable and is not included in refund calculation All refund requests must be made in writing by within 3 days of withdrawal. Please send all requests with your name, phone number, and class attended to: admin@questnursingeducationcenter.com. My signature below certifies that I have read, understood, and agreed to my rights and responsibilities and that the institution s cancellation and refund policies have been clearly explained to me. Student Name: Signature: Date: QuestNEC Representative Signature: Date: Quest Nursing Education Center 2135 Broadway Oakland, CA 94612

5 Admission Application Checklist Student Name: Signed Enrollment Application Filled out Eligibility Checklist Enclosed Fees (with selected payment plan) Signed Refund Policy Enclosed Copy of ID Quest Nursing Education Center 2135 Broadway Oakland, CA 94612