EmailMeForm
Clackamas Nursing Assistant Training Application
First Name
*
Last Name
*
Street Address 1
*
Street Address 2
City
*
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 #29 - Jul 5 through Aug 16, 2022
Class #30 - Aug 29 through Oct 11, 2022
Class #31 - Oct 31 through Dec 14, 2022
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 must complete the Healthcare Provider or Basic Life Support CPR course, which is not included in the tuition.
I understand that I must provide proof of at least two (2) doses of COVID-19 vaccine.
Image Verification
Please enter the text from the image:
[
Refresh Image
] [
What's This?
]
