CLASSIC NURSES ACADEMY
NURSE AIDE AND MEDICATION AIDE TRAINING PROGRAM
REGISTRATION INFORMATION

Tel: 703-658-9575

Today’s Date________________

Name: ________________________________________________

Last First Middle

Address: ______________________________________________

Street Number Street Name Apt. #

City State Zip Code

Home Telephone Number: (______) ________________________

Work Telephone Number: (______)_________________________

Date of Birth: ______/______/______Age:___________________

Month Day Year

Sex: Female____ Male____

Native Language: ___________________________________

Social Security #:_______- _____-____________________

Check One: Nurse Aide___________ Medication Aide_______

Transportation to and from the class and clinical training is the responsibility of the student.

Have you worked in the health care field before? Yes_____ No_______

If yes, please describe: _____________________________________

Why are you interested in taking this course?_________________________

_____________________________________________________________

How did you find out about the course? _____________________________

The course is limited to 10 (TEN) students per class. Once registration is closed, you will be asked to take a placement test. Registration is $25.00. The test will be offered free at the school premises. When all registration forms and fees are collected, and all testing is complete, you will be notified as to whether or not you are among a selected group for the course. For those receiving notification of acceptance into the course, tuition must be paid in full, or as agreed upon by the school accountant and the student, by the start of class.

Return this form to: Classic Nurses Academy

Nurse Aide and Medication Aide

Training Program

85. S. Bragg Street # 303

Alexandria, VA. 22312