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Clackamas Nursing Assistant Training Application
First Name
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Last Name
*
Street Address 1
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Street Address 2
City
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State
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Zip Code
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Email
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Phone
*
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Please select the class dates you wish to attend.
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Class #19 - Nov 5 through Dec 18, 2018
Class #20 - Jan 7 through Feb 20, 2019
Class #21 - Mar 4 through Apr 16, 2019
Class #22 - May 6 through Jun 18, 2019
Class #23 - Jul 8 through Aug 20, 2019
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 may 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 must complete the Healthcare Provider or Basic Life Support CPR course, which is not included in the tuition.
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