NURSING ASSISTANT TRAINING PROGRAM PROGRAM APPLICATION

ADMISSION STATUS ACCEPTED Finalized: DENIED Date: NURSING ASSISTANT TRAINING PROGRAM PROGRAM APPLICATION TONYA KENDRIX, MSN, MBA, HCM, RN PROGRAM DIRECTOR ABOUT THE PROGRAM The Nursing Assistant Training Program (NATP/CNA Program) at Warren Campus is designed to train individuals to care for residents or patients in hospitals, nursing homes, clinics, and even home health. Upon completion of the program, students will have an opportunity to obtain a CNA certificate for employment and will be eligible to pursue a practical nursing certificate upon completion of one semester of prerequisites. This Nursing Assistant Training Program/CNA Program is approved through the Office of Long Term Care (OLTC). All regulations and curriculum set by the OLTC are implemented and adhered to in the South Ark NATP/CNA program. NATP Students will be enrolled in a maximum of 12 credit hours. CNA Theory, Skills, Practicum, Ethics, and Medical Terminology for CNAs will meet on Mondays from 3pm until 7pm and Fridays from 8am until 2pm. First Aid-CPR class will be taught online during the semester. Financial Aid is available for students who can demonstrate appropriate need for financial assistance. Upon successful completion of the program, a certificate of proficiency will be awarded. This certificate will serve as a temporary license that is good for one year or until the state examination is completed. In addition to tuition, students are responsible for purchasing scrubs (solid red v neck, no prints), white leather shoes, a stethoscope, blood pressure cuff, gait belt, a watch with a second hand, and white lab jacket (long sleeves),and approximately $8.00 to cover the cost of the pin for the Pinning Ceremony. Students who qualify for Financial Aid will be able to use those funds towards the majority of these supplies. Additionally, a testing fee of $89.00 will be needed for the State Examination held at the end of the course. pg. 1

ENROLLMENT INTO THE COLLEGE Admission to SouthArk Community College is based on the following criteria: 1. Complete a SouthArk admissions application. Returning SouthArk students are not required to complete a new application. However, if you attended before 1986, a new application must be completed. You can complete the application online at www.southark.edu. 2. All official transcripts from any high school, colleges and universities, and technical or trade schools previously attended must be submitted to SouthArk Admissions. If you need to obtain a GED transcript, please submit your request to the AR GED Testing Office, Three Capitol Mall, Room 200, Luther Hardin Building, Little Rock, AR 72201-1083. 3. Provide proof of immunization to SouthArk Admissions. Two immunizations against measles and rubella (MMR) are required. 4. All first-time entering students and transfer students must submit placement test results from the ACT, SAT, ASSET or COMPASS. Students may take the COMPASS test via the SouthArk Learning Center. The exam takes approximately 1½ - 2 hours and costs $8.00. Students should call the Learning Center to schedule a time to take the exam and bring photo identification. The Learning Center phone number is: 870-864-7196. PROGRAM REQUIREMENTS Requirements for CNA Enrollment 1. Complete admissions process for SouthArk Community College. 2. Complete and submit the CNA application. 3. Provide a current state background check. 4. Provide results of TB skin test administered within the past 12 months. Chest x-ray results within the past 12 months must be submitted if previous results were positive. 5. Provide proof of flu vaccination administered within the past 12 months. If flu vaccine was not received, please bring documentation from your physician verifying why vaccine was not given. 6. Meet the program physical requirements for the program. Please read and sign acknowledgement on page 15 and 16 of this application. 7. Copy of your state issued driver s license or a state issued identification card Page 2 of 17

APPLICATION COMPLETEION 1. Please follow all directions carefully. The application will not be complete without all required information. A partially completed application will not be accepted. 2. Three recommendation forms are provided with this application. Ask your recommender to complete the form and return it by mail, or the student may return the form in a sealed envelope with the recommender s signature across the back flap. 3. Applicant will be notified by the CNA Program Director if an interview will be scheduled for the Nursing Assistant Training Program. 4. Applications will not be processed until ALL information has been received (including: TB Skin test, State background check, letters of recommendation, Completed SouthArk Admissions). 5. To be considered for the upcoming semester, completed applications must be received oneweek prior to the first day of class. 6. After all criteria have been met, an acceptance letter will be issued before enrollment. SUPPORT OF STUDENTS WITH DISABILITIES Students with special needs or requiring special need accommodations should contact the Vice President of Student Services. The college will work with any student to provide reasonable accommodations in accordance with the Americans with Disabilities Act. Page 3 of 17

DEMOGRAPHIC INFORMATION Type or Print the following information. Incomplete applications will not be accepted. Date Application Submitted Year of desired program admission Name Last First Middle Maiden Name Name you prefer to be called Social Security Number Student ID Number Date of Birth Driver s License Number Telephone: Home Business Alternate Address: Emergency Contact Information: Name Telephone Relationship to Student Address City State Zip Code Place of employment Telephone Family Physician Telephone Page 4 of 17

The following information is optional and used for statistical and affirmative action purposes. It does not affect eligibility for admission. Date of Birth / / Sex: Male Female Predominant Ethnic Background (check one) American Indian/Alaskan Native Asian or Pacific Islander Other White/Non Hispanic Black/Non Hispanic Prefer not to respond List in chronological order all Colleges, Universities, Vocational, Private, or any other institutions of higher learning previously attended. Use the transcript release form to request transcripts from any schools listed below. NAME OF INSTITUTION CITY STATE DATES ATTENDED TOTAL CREDIT HOURS If currently enrolled in any of the above institutions, list all courses. Final transcripts will be required prior to enrollment. Page 5 of 17

COURSE CREDIT HOURS COURSE CREDIT HOURS PERSONAL: Have you ever been convicted of a felony? Yes No Have you ever been convicted of a misdemeanor? Yes No Have you ever been convicted of child maltreatment? Yes No IF ANY ANSWER IS YES, PLEASE ATTACH EXPLANATIONMENT INFORMATION: Include all employment within the past five years beginning with the most recent. EMPLOYER CITY/STATE JOB RESPONSIBILITIES DATES FROM TO REASON FOR LEAVING Page 6 of 17

PERSONAL STATEMENT (AUTOBIOGRAPHY) In your own handwriting, please explain why you are seeking admission to a Health Science program. Include any information that you feel would assist in your selection to the program. This will help the Program Director and faculty to become better acquainted with you. If additional space is required, please attach additional pages. I hereby certify that the information contained in this application is true and complete to the best of my knowledge. I understand that any misrepresentation or falsification of information is reason for denial of admission to the Health Sciences Program. Applicant signature Date Page 7 of 17

NURSING ASSISTANT TRAINING PROGRAM RECOMMENDATION FORM To the Applicant: This recommendation form should be given to an individual who is in a position to comment on your qualifications for entering the Nursing Assistant Training Program. Please fill in your name and give the form to your recommender, along with a postage paid envelope for return mail to the Health Sciences Career Advisor. Student Name: Last First MI Maiden To the person making recommendation: The above individual has made application to the Nursing Assistant Training Program at South Arkansas Community College. Your assistance in completing this form is appreciated. The information will be used by the Program Director and faculty in the selection of students for admission to the program. How long have you known the applicant? In what capacity? Rate the applicant in terms of quality by checking the appropriate space listed below. CHARACTERISTICS SUPERIOR GOOD FAIR POOR UNKNOWN COMMENTS Intellectual Ability Dependability Attitude Motivation Ability to get along with others Ethical Behavior Self-Confident Maturity Initiative Attendance Reaction under Stress Honesty Page 8 of 17

Indicate below your recommendation of this applicant. Highly recommend Recommend Recommend, but with reservation Do not recommend Use the space below to make any additional comments. (Recommender please print or type the following information) Name Position/Title Institution Address Telephone Signature Tonya Kendrix, MSN, MBA, HCM, RN Program Director, CNA P.O. Box 7010 El Dorado, AR 71731-7010 PLEASE MAIL COMPLETED FORMS: Page 9 of 17

NURSING ASSISTANT TRAINING PROGRAM RECOMMENDATION FORM To the Applicant: This recommendation form should be given to an individual who is in a position to comment on your qualifications for entering the Nursing Assistant Training Program. Please fill in your name and give form to your recommender, along with a postage paid envelope for return mail to the Health Sciences Career Advisor. Student Name: Last First MI Maiden To the person making recommendation: The above individual has made application to the Nursing Assistant Training Program at South Arkansas Community College. Your assistance in completing this form is appreciated. The information will be used by the Program Director and faculty in the selection of students for admission to the program. How long have you known the applicant? In what capacity? Rate the applicant in terms of quality by checking the appropriate space listed below. CHARACTERISTICS SUPERIOR GOOD FAIR POOR UNKNOWN COMMENTS Intellectual Ability Dependability Attitude Motivation Ability to get along with others Ethical Behavior Self-Confident Maturity Initiative Attendance Reaction under Stress Honesty Page 10 of 17

Indicate below your recommendation of this applicant. Highly recommend Recommend Recommend, but with reservation Do not recommend Use the space below to make any additional comments. (Recommender please print or type the following information) Name Position/Title Institution Address Telephone Signature Tonya Kendrix, MSN, MBA, HCM, RN Program Director, CNA P.O. Box 7010 El Dorado, AR 71731-7010 PLEASE MAIL COMPLETED FORMS: Page 11 of 17

NURSING ASSISTANT TRAINING PROGRAM RECOMMENDATION FORM To the Applicant: This recommendation form should be given to an individual who is in a position to comment on your qualifications for entering the Nursing Assistant Training Program. Please fill in your name and give form to your recommender, along with a postage paid envelope for return mail to the Health Sciences Career Advisor. Student Name: Last First MI Maiden To the person making recommendation: The above individual has made application to the Nursing Assistant Training Program at South Arkansas Community College. Your assistance in completing this form is appreciated. The information will be used by the Program Director and faculty in the selection of students for admission to the program. How long have you known the applicant? In what capacity? Rate the applicant in terms of quality by checking the appropriate space listed below. CHARACTERISTICS SUPERIOR GOOD FAIR POOR UNKNOWN COMMENTS Intellectual Ability Dependability Attitude Motivation Ability to get along with others Ethical Behavior Self-Confident Maturity Initiative Attendance Reaction under Stress Honesty Page 12 of 17

Indicate below your recommendation of this applicant. Highly Recommend Recommend Recommend, but with reservation Do not recommend Use the space below to make any additional comments. (Recommender please print or type the following information) Name Position/Title Institution Address Telephone Signature Tonya Kendrix, MSN, MBA, HCM, RN Program Director, CNA P.O. Box 7010 El Dorado, AR 71731-7010 PLEASE MAIL COMPLETED FORMS: Page 13 of 17

South Arkansas Community College P.O. Box 7010 El Dorado, AR 71731-7010 870.862.8131 AUTHORIZATION TO RELEASE OFFICIAL TRANSCRIPT *NOTE TO STUDENT: CONTACT COLLEGE FOR FEE INFORMATION PRIOR TO MAILING. Please send one (1) official copy of my transcript. Also send ACT, ASSET or COMPASS scores and Immunization Records, if available. NAME LAST FIRST MIDDLE MAIDEN ADDRESS STREET CITY STATE ZIP SOCIAL SECURITY NUMBER DATE OF BIRTH Name and address of college or high school attended. (Please complete a separate form for each institution.) COLLEGE NAME ATTENTION: TRANSCRIPTS STREET ADDRESS CITY, STATE, ZIP Last date you attended the institution listed above: MAIL TRANSCRIPT TO: SOUTH ARKANSAS COMMUNITY COLLEGE ENROLLMENT SERVICES P. O. BOX 7010 EL DORADO AR 71731-7010 Page 14 of 17

PHYSICAL REQUIREMENT ACKNOWLEDGEMENT NURSING ASSISTANT TRAINING PROGRAM Each student seeking enrollment into the Nursing Assistant Training Program at South Arkansas Community College must meet each of the following physical requirements to further the likelihood of successful completion of the program. Please note that each student are required to meet all requirements including physical and academic requirements set by the program director with a passing grade of 80% C or higher in order to successfully complete the program and sit for the state licensure exam. PHYSICAL REQUIREMENTS: Students must be able to lift, push, and pull at least 50 lbs., Stand/work for 8 hours performing skills and providing direct patient care, Squat, stoop, bend, and kneel frequently Must be able to carry and/or transfer objects or persons weighing 50 lbs. or greater, Applying up to 10 pounds of pressure in performing CPR. Reacting appropriately and professionally under stressful situations. Communicating effectively, both orally and in writing, using appropriate grammar and vocabulary. Page 15 of 17

FAILURE TO MEET REQUIREMENTS Students who fail to meet the physical requirements of the Nursing Assistant Training Program are potentially subject to physical injury related to the physical demands associated with the Nursing Assistant job duties. Students who have or have previous had physical injuries or medial conditions that would likely conflict with his/her ability to meet the physical requirement of the Nursing Assistant Training Program should: Submit a signed letter or document from his/her medical physician with the student s weight limitations in pounds and any needs related to his/her ability to meet the physical requirement of the program. Students must also seek assistance from student support counselors at SouthArk to address making accommodations while in the program. Seek advising from the SouthArk Career Advisor for alternate career options should physical abilities hinder or potentially hinder his/her program success. Page 16 of 17

NURSING ASSISTANT TRAININT PROGRAM PHYSICAL REQUIREMENT ACKNOWLEDGEMENT Read the following questions and statement carefully. QUESTION Can you perform the following physical abilities as required by the Nursing Assistant Training program? Students must be able to lift, push, and pull at least 50 lbs., Stand/work for 8 hours performing skills and providing direct patient care, Squat, stoop, bend, and kneel frequently Able to carry and/or transfer objects or persons weighing 50 lbs. or greater Applying up to 10 pounds of pressure in performing CPR. Reacting appropriately and professionally under stressful situations. Communicating effectively, both orally and in writing, using appropriate grammar and vocabulary. ACKNOWLEDGEMENT YES NO By signing in the space provided, I acknowledge that I have read the Physical Requirement Acknowledgement and agree to the terms outlined above. I hereby certify that the information contained in this acknowledge is true and complete to the best of my knowledge. I understand that any misrepresentation or falsification of information that I provide in this agreement or submit to the program director is reason for denial of admission to the Health Sciences Program. Should any injury occur as a result of my falsification or misrepresentation of information related to my physical ability I am liable for such damages or injuries. Signature: Date: Page 17 of 17