EmailMe Form - Clackamas Nursing Assistant Training Application

First Name *
Last Name *
Street Address *
City and State *
Zip Code *
Email *
Phone *
### - ### - ####
How do you prefer to be contacted *

Yes No

I will respond to text messages

I will respond to Email messages

I will respond to voice or voicemail
Please select the class dates you wish to attend. *
Class #35 - Sep 11 through Oct 9, 2023
Class #36 - Nov 6 through Dec 5, 2023
Please enter any questions or comments you may have:

You MUST answer the following questions: *

	Yes	No
I understand that completing this application does not guarantee me admission into the program.
I understand that I will be asked to submit to a drug screen.
I understand that I must submit to a criminal background check by a vendor that meets the requirements of the Oregon Health Authority.
I am able to speak, read, write, and understand the English language.
I understand that I must complete the Basic Life Support CPR course, which is not included in the tuition.

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