Nightingale Healthcare Prfessinals Phne: (510) 553-1800 Fax: (510) 553-1818 Email: inf@nightingalehealthcareprfessinals.cm Website: www.nightingalehealthcareprfessinals.cm NURSING ASSISTANT TRAINING PROGRAM ADMISSION APPLICATION Name: Driver License r State ID Number: State: Height: Weight: Date f Birth: SS#: Address: City: State: Zip: Phne: ( ) cell r hme (circle ne) Email Address: @ Occupatin: Emplyer: EMERGENCY CONTACT: Name: Relatinship: Tel: ( ) Alternate Phne: ( ) EDUCATIONAL BACKGROUND (HIGHEST EDUCATION ATTAINED): ATTENDED HIGH SCHOOL SOME COLLEGE POST COLLEGE HIGH SCHOOL DIPLOMA/GED ASSOCIATE/BACHELOR S DEGREE WORK EXPERIENCE: (PLEASE LIST BEGINNING WITH MOST RECENT) YEAR JOB TITLE OCCUPATION/EMPLOYER DUTIES & RESPONSIBILITIES Hw did yu find ut abut Nightingale Healthcare Prfessinals?: Persnal Referral (name) Faxed / Psted flyer (place) Other (please be specific) I hereby certify all the abve t be true and crrect t the best f my knwledge Tday s Date: Signature f Applicant "Yur Future in Healthcare Starts Nw!"
Nightingale Healthcare Prfessinals Phne: (510) 553-1800 Fax: (510) 553-1818 Email: inf@nightingalehealthcareprfessinals.cm Website: www.nightingalehealthcareprfessinals.cm NURSING ASSISTANT TRAINING PROGRAM ENROLLMENT AGREEMENT Name: Date f Birth: SS#: Address: City: State: Zip: Phne: C ( ) H: ( ) TOTAL CLOCK HOURS OF INSTRUCTION: 150 Hurs (50 hurs Thery & 100 hurs Clinical) PROGRAM LENGTH: Varies per time f prgram yu select. SPECIFIC TIMES OF CLASS ATTENDANCE (DAY PROGRAM): SPECIFIC TIMES OF CLASS ATTENDANCE (EVENING PROGRAM): 8:30 am 4:30 pm 4:30 pm 9:30 pm *DAYS AND TIMES SUBJECT TO CHANGE* TYPE OF DOCUMENT AWARDED UPON COMPLETION: Upn successfully cmpleting all requirements f the curse, the student will receive a Certificate f Cmpletin. Scheduled Start Date: Scheduled Cmpletin Date: FEES AND CHARGES Applicatin Fee (nn -refundable) $ 150.00 Nursing Assistant Training Prgram Fee: $ 900.00 Ttal Nursing Assistant Training Prgram Fee $ 1,050.00 Additinal Fees - Students Respnsibility ARC Testing Fee Unifrms Stethscpe (ptinal) Gait Belt (ptinal) White Shes with slip resistant sle Watch with secnd hand "Yur Future in Healthcare Starts Nw!"
Nightingale Healthcare Prfessinals Phne: (510) 553-1800 Fax: (510) 553-1818 Email: inf@nightingalehealthcareprfessinals.cm Website: www.nightingalehealthcareprfessinals.cm CERTIFIED NURSING ASSISTANT TRAINING Once yu have successfully cmpleted the Certified Nursing Assistant training prgram at Nightingale Healthcare Prfessinals and passed the American Red Crss (ARC) cmpetency exam, as a graduated yu will be perfectly psitined t begin wrking at the entry level in the health care field. Yu can literally be n yur way and climbing the career ladder that leads t heights in the medical field nly limited by the student themselves. A firm healthcare training backgrund prvides the basis fr a transitin int ther patient care areas including LVN, RN, nurse practitiner, PA, etc. CNA training is a truly viable ptin fr all participants: The U.S. Bureau f Labr Statistics estimates that healthcare related ccupatins are and will cntinue t be the fastest grwing area f emplyment fr the next decade. The training perid required is 150 hurs; there are n pre-requisites, n requirements f a high schl diplma r GED. The hurs are brken dwn int 50 hurs f thery and 100 hurs f hands-n training. We train with residents wh reside in skilled nursing facilities. The maximum student teacher rati is 15:1 thereby allwing thse students requiring special attentin t receive it. We truly have a "n student left behind" philsphy. Emplyment is usually btained immediately after passing the American Red Crss Certificatin Test. We ffer assistance with jb placement as sn as yu begin the prgram there are ptins t begin yur career as well. A CNA can literally wrk any given hurs f the day r night. Many careers are restricted t day time and evening hurs, which is nt the case with the CNA. There are night shifts as well as vernight shifts. A lt f facilities are s shrt staffed that there are can als be a lt f vertime available which is paid at a rate f time and a half fr 9 t 12 hurs and duble time fr 13 t 16 hurs. The average starting salary fr a CNA is arund $14 an hur with benefits fr thse wh wrk a full time schedule. Additinal Benefits t furthering yur educatin with Nightingale: 1. The training lcatin, at 8105 Edgewater Dr. Suite 290, Oakland is n a majr bus rute fr thse traveling by public means. Fr thse driving, there is plenty f free parking - n searching fr parking places n the street r wrrying abut having timed meters. 2. We ffer jb assistance by prviding students with verified jb leads, in the frm f phne numbers, addresses and cntact persn(s) t ver 50 nursing hmes acrss the east, nrth and suth Bay Area. 3. We can ffer assistance with resume preparatin and caching, interview skills develpment and prper attire. Letters f recmmendatin are als available fr students in gd standing.
PAGE 2 CERTIFIED NURSING ASSISTANT TRAINING 4. The classes are small with 15:1 student/instructr ratis, and individualized attentin. 5. We have excellent relatinships with the Nursing Facilities where students receive their clinical training, and where sme students have been placed in emplyment capacities. Fr enrllment and training questins, cntact ur ffice at 510-553-1800. Prgram Cst and Fee Breakdwn: $150 Applicatin & Registratin Fee (Bk included) $900 Training & Instructin Fee Ttal Fees $1,050 The ttal f $1,050 can be paid in full r a payment agreement can be set up. All fees must be cmpleted befre the end f the prgram. Other csts t student: America Red Crss Cmpetency Testing Fee BLS (CPR Certificatin) OPTIONAL Live Scan $105 $80 (Includes Mandatry Bk) $49 (varies per lcatin) NOTE: These prices are based n prices frm Unifrm Advantage n Christie Ave in Emeryville. They will give 10% ff these prices if yu tell them yu will be a NHP Student. Yu may chse t get yur supplies frm anther stre if yu wish. Analg watch with secnd hand Wine unifrm (scrubs) $23.00 $30.00 White r Black shes $30.00 Stethscpe - B/P cuff (cmbinatin) $40.00 Gait Belt $12.99 Requirements fr Prgram: Pass a criminal backgrund check thrugh the Live Scan. Obtain TB test and clearance (Can be frm within the past 3 mnths); Obtain a physical (Can be frm within the past 3 mnths) and a flu sht during the dates f Octber 1 st thru March 31 st nly (flu seasn). Nightingale Healthcare Prfessinals "Yur Future in Healthcare Starts Nw!" (510) 553-1800 fax (510) 553-1818
Nightingale Healthcare Prfessinals Phne: (510) 553-1800 Fax: (510) 553-1818 Email: inf@nightingalehealthcareprfessinals.cm Website: www.nightingalehealthcareprfessinals.cm THESE TESTS MUST BE COMPLETED BEFORE ANY DIRECT PATIENT CONTACT Please make arrangements t cmplete these requirements befre the first day f class. A TB test, Livescan, Physical and Flu Sht (flu seasn Oct 1 thru Mar 31) are necessary t participate in clinical. Yu cannt miss class hurs t get tests cmpleted. TB TESTS AVAILABLE AT THIS LOCATION: - Berkeley Free Clinic: 2339 Durant Avenue Berkeley, CA 94704 Cst: Free Call (510) 548-2570 at 5:45 pm t schedule an appintment - Rts Cmmunity Health Center: 9925 Internatinal Blvd #5 Oakland Ca 94603 Cst: $25 Call (510) 777-1177 t schedule an appintment LIVESCAN AND PHYSICALS AVAILABLE AT THIS LOCATION: N appintment needed Occupatinal Testing Center 1 Market Street Oakland, Ca 94607 (510) 836-0448 Physical $40 Open Mnday Friday Livescan $52 Open Mnday Friday PHYSICAL, TB TEST AND FLU SHOTS AVAILABLE AT THIS LOCATION: Open Mn Fri 10 am - 4:30pm N appintment needed Dr. Knstantin 2584 MacArthur Blvd. Oakland, CA 94602 (510) 530-5400 $50 fr all 3 (best value) $30 TB test nly $30 Physical nly Flu sht free with TB r Physical "Yur Future in Healthcare Starts Nw!"
Nightingale Healthcare Prfessinals Phne: (510) 553-1800 Fax: (510) 553-1818 Email: inf@nightingalehealthcareprfessinals.cm Website: www.nightingalehealthcareprfessinals.cm Medical Examinatin Reprt STUDENT NAME: S.S. # DATE OF BIRTH: Please have the examiner fill ut the infrmatin requested in each area. In sme cases, nly a MD may verify treatment f medical clearance t participate in the Nursing Prgram. Turn in cmpleted frm t NHP administrative ffice n the first day f class. Please Circle: MALE FEMALE DATE OF EXAMINATION: HEIGHT : WEIGHT : PULSE: /MIN RESP BLOOD PRESSURE: VISUAL ACUITY: VISUAL ACUITY WITH CORRECTIVE LENS: RT EYE: LEFT EYE: RT EYE: LEFT EYE: CHECKLIST NORMAL ABNORMAL DETAILED DESCRIPTION OF ABNORMAL FINDINGS HANDS/SKIN HEAD/EYES EAR/NOSE/THROAT/MOUTH NECK/NODES CHEST/LUNGS CARDIOVASCULAR ABDOMEN MUSCULOSKELETAL NERVOUS SYSTEM "Yur Future in Healthcare Starts Nw!"
Nightingale Healthcare Prfessinals Phne: (510) 553-1800 Fax: (510) 553-1818 Email: inf@nightingalehealthcareprfessinals.cm Website: www.nightingalehealthcareprfessinals.cm STUDENT EXAMINATION OUTCOME I have examined and fund that the student is FREE f (Student's Name) cmmunicable diseases and des nt have any cnditin that wuld create a hazard t himself/herself, fellw students, patients, and visitrs. I have examined and fund a cnditin at (Student's Name) this time that appears t PREVENT this persn frm fulfilling the requirements as described abve. (Please describe cnditin and recmmendatins belw.) Physician s Printed Name: Physician s Signature: Address: Telephne Number: TB TEST Intradermal Skin Test (PPD Mantux) Date Tested Result If Psitive skin test, a medical physician must enter in the fllwing infrmatin: Date f Chest X-ray: (Within the Past Year) Result : Chest X-ray and Questinnaire must be dne annually Has this patient been prescribed any Chemtherapy t treat TB? What medicatins are prescribed and what prescriptin/regimen? Flu Sht (Flu Seasn Octber March) I have given the (Student's Name) (Flu sht Series) PHYSICIAN'S SIGNATURE: "Yur Future in Healthcare Starts Nw!"
STATE OF CALIFORNIA BCIA 8016 (rig. 4/2001; rev. 01/2011) DEPARTMENT OF JUSTICE Applicant Submissin A1226 ORI (Cde assigned by DOJ) Certificatin Certified Nurse Assistant (CNA) r Hme Health Aide (HHA) Authrized Applicant Type Type f License/Certificatin/Permit OR Wrking Title (Maximum 30 characters - if assigned by DOJ, use exact title assigned) Cntributing Agency Infrmatin: Califrnia Department f Public Health (CDPH) 03314 Agency Authrized t Receive Criminal Recrd Infrmatin MS 3301, P.O. Bx 997416 Street Address r P.O. Bx Sacrament CA 95899-7416 City Applicant Infrmatin: REQUEST FOR LIVE SCAN SERVICE Mail Cde (five-digit cde assigned by DOJ) Cntact Name (mandatry fr all schl submissins) State Zip Cde Cntact Telephne Number Last Name First Name Middle Initial Suffix Other Name (AKA r Alias) Date f Birth Last Sex Male Female First Name Height Weight Eye Clr Hair Clr Billing Number Misc. Place f Birth (State r Cuntry) Scial Security Number Number Driver's License Number (Agency Billing Number) (Other Identificatin Number) Suffix Hme Address Street Address r P.O. Bx City State Zip Cde Yur Number: Scial Security Agency Identificatin Number) OCA Number If re-submissin, list ATI number: (Must prvide prf f Rejectin) Level f Service: DOJ FBI Original ATI Number Emplyer (Additinal respnse fr agencies specified by statute): Nightingale Healthcare Prfessinals Emplyer Name 8105 Edgewater Dr., Ste. 290 Street Address r P.O. Bx Oakland CA 94621 Mail Cde (five-digit cde assigned by DOJ) City State Zip Cde Telephne Number (ptinal) Live Scan Transactin Cmpleted By: Name f Operatr Date Transmitting Agency LSID ATI Number Amunt Cllected/Billed ORIGINAL - Live Scan Operatr SECOND COPY - Applicant THIRD COPY (if needed) - Requesting Agency