Registration Medication Aide Course office- month Name: Social Security #: Email: _ of Birth: Present Address: No. Street City County State Zip Home Telephone #: Cell #:_ Alternate Contact Name: Phone #: Education Type of School Name & City Graduated Degree/Course Major High School Yes No College Yes No Other Yes No Employment Experience From:Employer:_Supervisor: To: Address: Telephone #: Describe Duties: From:Employer:_Supervisor: To: Address: Telephone #: Describe Duties: Why do you want to be a CMA? I certify that, to the best of my knowledge and belief, the answers and statements given by me in this application are complete and correct. I understand that Interim HealthCare will not enroll individuals who use any controlled substance, in any amount, regardless of the frequency or occasion, without a medically acceptable prescription. I hereby release any persons providing information hereunder, and their agents, from any liability resulting from the release of such information. If I am accepted and subsequent investigation discloses that anything contained in this application is untrue, I understand I will be subject to expulsion at any time. I understand and agree, upon course completion, that employment with Interim Health Care is not guaranteed. Signature Interviewer
Enrollment Agreement I have read the admission requirements and the General Course Information. My questions have been answered and I sign in agreement. Holder in Due Course Rule: Any holder of this consumer credit contract (enrollment agreement) is subject to all claims and defenses which the debtor could assent against the seller of goods or services obtained pursuant hereto with the proceeds hereof, recovery hereunder by the debtor shall not exceed amounts paid by the debtor hereunder. Student Signature Witness 2
NOTIFICATION OF CRIMINAL BACKGROUND CHECK Interim HealthCare requires all Medication Aide Students to pass a criminal background check. This agency will forward the relevant identifying information to the reviewing agencies stated below for review. Any person found to have a record for certain specified crimes cannot be offered the instruction in our Medication Aide School and will be withdrawn from the program. I have been informed that this training center will request a background check on me in the following areas and any other searches as deemed necessary: Oklahoma State Bureau of Investigation Sex and Violent Offender Registry Oklahoma Nurse Aide Abuse Registry HHS-Office of Inspector General Full name of Student, including maiden and all married names Social Security Number of Birth Signature of Student Training Center Representative 3
2828 E. 51 st St. Tulsa, OK 74105 918-749-9933 CERTIFIED MEDICATION AIDE STATEMENT OF ATTESTATION I attest that I, _, meet all the following requirements for certification as a medication aide. (Please initial beside each): I am at least 18 years of age. I have a high school diploma or a general equivalency diploma (GED). I have a current Oklahoma nurse aide certification with no abuse notations. I have at least six months experience working a certified nurse aide. I have the physical and mental capability to perform the duties of a certified medication aide. _ Candidate Signature of Signature Candidate Name (printed) Signature of Training Supervisor 4
INTERIM TRAINING CENTER MEDICATION AIDE TRAINING PAYMENT AGREEMENT NAME: CLASS START DATE FINAL CLASS DATE: TOTAL COST: DEPOSIT: ($50.nonrefundable/transferrable) PAYMENT: PAYMENT AGREEMENT: Received Items: Medication Aide Txtbk loaner: # Student Interim HealthCare witness Photo ID CNA Cert CPR Cert TB Test MMR Drug Screening is to be completed two weeks before class begins. 5