CNA GNA Application

Are you currently receiving any of the following benefits?

Today's Date

Date

Name

First NameMiddle NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Social Security Number

Home Phone

Please enter a valid phone number.Format: (000) 000-0000.

Mobile Phone

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Gender

Race/Ethinicity

Emergency Contact Name

First NameLast Name

Emergency Contact Relationship

Emergency Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact Phone

Please enter a valid phone number.Format: (000) 000-0000.

How did you hear about It Works Learning Center?

Which training are you interested in?

Other

Have you ever applied for enrollment to an It Works course before?

Do you have any outstanding State of Maryland Tax Liens?

If yes, how much?

Do you have a valid government issued picture ID?

Do you have your original Social Security Card?

Do you have a Birth Certificate, Passport or proof of address?

Do you have a Permanent Resident/Green Card or I-94? (foreign born)

If yes, which one?

Did you previously have your CNA or GNA license?

If yes, explain.

Do you have a High School Diploma or G.E.D.? (Not required)

Do you receive benefits from DSS (Food Stamps, TCA)?

If yes, please provide CID#

Due to COVID-19, all classes are held virtually until further notice. Do you have access to a computer and internet access so that you can participate in online courses?

When are you Working or in School? Identify times/shifts:

Identify all appointments that may prevent you from attending class:

If enrolled in this class, will you be able to attend ALL weeks of class?

Signature

If enrolled in this class, will you accept full-time employment for at least 1 year?

Signature

When do you want to work?

Please list information for all schooling including high school, technical school, and college. Include school names, addresses, degrees, and graduation dates.

Are you willing to submit for a drug screen, which includes marijuana or THC use in the last 90 days?

Have you ever been arrested, charged with a crime, listed as a defendant or discussed your case with a judge?

If Yes, explain ALL instances, noting state and year of occurrence(s), charges (misdemeanor or felony), status/outcomes(Pending, Warrant, Guilty, Not Guilty, Probation Before Judgement (PBJ), STET, Nolle Prosequi (Nol Pros), etc.), and relevant details, including ALL expunged records, regardless of location, age, date or relevance. Include traffic charges, but not parking tickets. Include the state, date, charges, outcome, and details.

PROGRAM REQUIREMENTS: PROFESSIONALISM: Students must be willing to learn, able to work on a team and have a focused and committed demeanor, including appropriately exhibited attitude, behavior, class participation, attention to timeliness/lack of tardiness, good communication skills, work ethic and people skills. PHYSICAL ABILITIES: Students will be required to meet the same physical demands as are required by employees of a nursing home. This includes intermittent and even prolonged physical activity, such as walking,standing, sitting, and lifting as much as 50 lbs. or more. If you have any pre-existing condition that may prevent you from performing any skills or activities required of students attending this program, written verification must be provided from your physician, stating that there are “no activity restrictions.” HONESTY: Students need to possess strong integrity and trust. Lying, cheating, stealing or other dishonest or unacceptable behavior will not be tolerated and are grounds for immediate removal from this program. ATTENDANCE: A minimum of 90% attendance is required for the classroom lecture and skills. You must attend all 100% of the 40 hours of clinical rotation. Lateness will be factored into attendance. GRADES: All classroom modules must be completed with an average score of 80%. A score of 80% or better must be achieved on the final exam. OTHER: All obligations to grant, funders, and It Works Learning Center, Inc. must be met.

Prior Work Experience (Begin with your most recent employer. If unemployed, write Unemployed.) Include employers name, address, phone number, start date/end date, pay rate, position/title, supervisor, and reason for leaving.

I understand that, if I am accepted into this training program, false statements on this application or providing falsified documents will be considered sufficientgrounds for my declination or removal. I understand and agree that my acceptance into this training program is contingent upon a satisfactory criminalbackground check. I further understand that a drug screen may be conducted, and a positive test will automatically disqualify me from consideration for thisprogram.I hereby authorize It Works Learning Center, Inc. and its agents to contact any and all corporations, former employers, educational institutions, lawenforcement agencies, city, state, county and federal courts and military services to release information about my background, including, but not limited to,information about my employment, education, driving record, criminal record, and general public records history. I consent to the release of this applicationand all other information, documents and agreements that I provide to or enter into with It Works Learning Center, Inc. to the facility hosting the training,and, if different, the employer where I am seeking employment, as well as any source of my tuition. I consent to photos being taken of me and used in promotionaland marketing materials, for which I will receive no compensation. Following completion of this training program, I furthermore consent to the release of myemployment information by my employer to It Works, to include my hire date, pay rate and, if applicable, separation date and reason. I release the aforesaidparties from any liability and responsibilities for collecting or sharing the above information. I believe to the best of my knowledge that all information I haveprovided is accurate, true and correct.

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