Excelling Nursing Academy


25820 Orchard Lake Rd.
Farmington Hills, MI 48336

248-313-2275
info@excellingnursingacademy.com

Register for Classes at Excelling Nursing Academy, Inc. Today!

Personal Information

Last Name:   First Name:   Middle: 

Home address:    City:    State:    Zip:   

Daytime phone:    Evening phone:   

Email address:   

Education/Enrollment

Have you graduated from High School? Yes   No

Have you passed the GED?Yes   No   N/A

Are you at least 16 years old? Yes   No 

Are you currently a:   Sophomore  Junior  Senior in High School  N/A

High School student must secure permission through their school principal (see form below)

Have you ever been convicted of a felony? Yes   No

If yes, please list:

Can you commit to 14 days of class? Yes   No
Attendance in mandatory!!

If the session is full, do you want to be put on a waiting list? Yes   No

Emergency Contact Information
Name:    Relationship   
Address:    Phone:   

CNA supports students with disabilities.
Are you an applicant with a documented disability? Yes   No

If yes, please explain:

Is English your first language? Yes   No
If not, what is your first language? 

Why do you want to attend the CNA course?

What personal qualities do you think a successful CNA should have?

Are you thinking of making healthcare a career? Yes   No
If yes, what area of healthcare are you considering?

TB skin tests will be administered on the 5th class. Positive tests require chest x-rays.
Students that have had a TB/PPD test within the last 12 months, may bring the results into the school.

Certification

I certify that all the answers given in this application are accurate to the best of my knowledge.
I understand that failure to disclose or falsifying information could result in my dismissal from the CNA course.

Signature:    Date:   

Parent signature if under 18 years of age:     Date:   

Print these forms and submit them to the Academy at the address below:
High School Permission form (if applicable)
Disclosure and Authorization form (required)

 


Basic Life Support Classes

Basic Life Support Classes

Heart Saver Classes

Heartsaver® Classes

First Aid and CPR Classes

First Aid/CPR Classes

Excelling Nursing Academy, Inc. • 25820 Orchard Lake Rd.    Farmington Hills, MI 48336    248-313-2275    info@excellingnursingacademy.com
Excelling Nursing Academy, Inc. on Twitter Excelling Nursing Academy, Inc. on Pinterest Excelling Nursing Academy, Inc. on Instagram Excelling Nursing Academy, Inc. on LinkedIn Excelling Nursing Academy, Inc. on Facebook