APPLICATION FOR EMPLOYMENT

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					                                       ENROLLMENT CONTRACT
DATE OF APPLICATION:                                                        Account ID. :


Start Date:                                                                 Graduation Date:



                                       PLEASE CHECK WHICH PROGRAM YOU INTEND TO TAKE



  □   Certified Nursing Assistant                                       DAY SESSION
  □   Certified Nursing Assistant II                                    NIGHT SESSION


 PERSONAL INFORMATION
 NAME (LAST NAME FIRST)                                                 PHONE NO.                                  CELL NO.
                                                                        (      )                                   (   )
 PRESENT ADDRESS


 PERMANENT ADDRESS


 SOCIAL SECURITY NO.            DATE OF BIRTH:   REFERRED BY


 E-mail:                                         Country of Birth:                                  Country of Citizenship:

 ARE YOU                               HOW DID YOU
 CURRENTLY
 EMPLOYED?
                  □   YES   □    NO    FIND OUT
                                       ABOUT OUR
                                                       □   AD        □       Internet       □   Yellow Pages   □   Brochure   □   Other
                                       SCHOOL:
 Have you ever been
 certified as a nursing     □    YES   □   NO          IF YES, PLEASE INDICATE YOUR CNA LICENCE NO. AND STATE:
 assistant?




 EDUCATIONAL BACKGROUND
                            SCHOOL NAME                         DATES                   GRADUATED?             SUBJECTS?
                            & LOCATION                                                  (IF APP.)              (IF APP.)


 HIGH SCHOOL



 COLLEGE


                            SCHOOL NAME                         DATES                   GRADUATED?             SUBJECTS?
                            & LOCATION                                                  (IF APP.)              (IF APP.)
 BUSINESS, TRADE OR
 CORRESPONDENCE
 SCHOOL(S)

 WHY DO YOU WANT
 TO TAKE THIS
 COURSE?
EMPLOYMENT HISTORY
DATE                    NAME & ADDRESS              ENDING            POSITION          REASON FOR
MONTH & YEAR            OF EMPLOYER(S)              SALARY              HELD             LEAVING
FROM/TO:

FROM/TO:

FROM/TO:



                                           REFERENCES
REFERENCES GIVE BELOW THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST 1 YEAR
NAME                     ADDRESS & PHONE NO.                  TYPE OF BUSINESS            YEARS KNOWN




                             PLEASE DO NOT WRITE BELOW THIS LINE
INTERVIEWER’S COMMENTS




                                                    □   Yes      □   No
 Copy of Driver’s License Obtained:                                       License #:
                                                    □   Yes      □   No
 Student Liability Insurance Obtained:                                    Policy #:
                                                  CERTIFICATION


        “I certify that the information I have provided in this enrollment application is true and complete
 to the best of my knowledge and I understand that one or more falsified statements within this
 application is grounds for refusal.

        I authorize investigation of all statements contained herein and, the references and I release
 the school from all liability for any damage that may result from use of said information.

         I also understand and agree that no representative of the school has any authority to enter into
 any agreement for any specified period, or to make any agreement contrary to the foregoing, unless it
 is in writing and signed by an authorized school representative.

        This waiver does not permit the release or use of disability-related or medically-related
 information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant
 federal and state laws.”


  EMPLOYMENT DISCLAIMER:

  NV Enterprises Training Academy will make all reasonable efforts to assist a student with
  employment; however, NV Enterprises Training Academy, or any of its employees cannot guarantee
  employment to a student enrolled in, or s student who has completed anyone of our training
  programs.



 DATE                                        SIGNATURE



 INTERVIEWED BY                                                                           DATE




                                                     EEO ASSURANCE

Section 188 of the Workforce Investment Act of 1998 (WIA), which prohibits discrimination against all individuals in the
United States on the basis of race, color, religion, sex, national origin, age, disability, political affiliation or belief, and
against beneficiaries on the basis of either citizenship/status as a lawfully admitted immigrant authorized to work in the
United States or participation in any WIA Title I financially assisted program or activity; Title VI of the Civil Rights Act of
1964, as amended, which prohibits discrimination on the basis of race, color and national origin; Section 504 of the
Rehabilitation Act of 1973, as amended, which prohibits discrimination on the basis of age, and The Age Discrimination
Act of 1975, as amended, which prohibits discrimination on the basis of age; and Title IX of the Education Amendments.
                                                   FINANCE POLICY




                                               TERMS & CONDITIONS
WEEKLY PAYMENTS: Payment arrangements can be made and all such payments are due weekly and must be paid each Friday
                        by 4:00 pm. If payments are not received by 4:00 pm, there will be a 5% late fee assessed to student’s
                        outstanding balance on their account. If payment is not received by the following week, student may
                        not be allowed to continue in class. Final payment is due before student’s final exams and payment must
                        be made by CASH, MONEY ORDER or CREDIT CARD -NO PERSONAL CHECKS will be accepted in the
                        final week. If final payment or any other outstanding charges are not received in full, student will not
                        be allowed to take their final exam, attend clinical, graduate with class or receive a certificate of
                        completion. Without this Certificate you will not be able to take your Georgia State C.N.A.
                        examination. _________ (Initial)

REGISTRATION FEE: Once notified of conditional acceptance, the student will receive an enrollment agreement.                     A $200
                        registration fee is required to confirm the intention to attend the school and to reserve a place in the entering
                        class. The registration fee is applicable towards tuition, and is non-refundable. _________
                        (initial)


RETURNED CHECKS: Checks that are returned because of insufficient funds will be charged a $50.00 Administration Fee. _____
                        (Initial)

REFUND:                 This refund policy adheres to all applicable regulations of the state of Georgia and is described
                        below:

                             a. Registration fee paid by the prospective student is refundable minus a 15% fee if he/she
                                requests same within three (3) business days after first making the payment to the
                                school. A cancellation notice must be received by certified mail. _____(Initial)

                             b. All down payments (this does not include registration fee) are credited to your tuition
                                balance unless clearly identified on receipt by the school as application or other fees.
                                _____(Initial)

                             c.     The application fee of $40.00 is non-refundable and is only charged once unless
                                    applicant is entering an unrelated program, or unless the applicant previously withdrew
                                    from the school. If a student withdraws from the school for any reason, the student is not
                                    liable for any unpaid portion of the application fee. _____(Initial)


                             d. If a student withdraws before completing fifty (50) percent of instructional time, any
                                unused portion (as well as the terms in section a.) of the fees is refunded by the school.
                                _____(Initial)


                                    A student is recorded as having terminated his or her program of study on the date in
                                    which the student has begun the official withdrawal process or otherwise provided official
                                    notification of this or her intent to withdraw as prescribed by the school. For students
                                    who attend beyond the first week of classes and who withdraw without notification to the
                                    school, the withdrawal date is the midpoint of the period of enrollment. Refunds will be
                                    calculated based upon the official notification date of the student’s withdrawal or, in the
                                    case of an unofficial withdrawal, the midpoint date of the period of enrollment. Refunds
                                    shall be made in full to the contracting party within thirty (30) days of the date of
                                    withdrawal as determined by the school. A written notice of withdrawal must be received
                                    from the student by certified mail. _____ (Initial)
FINANCE POLICY - Cont’d


                   e. Refunds are based on tuition paid for each segments of the instructional program as
                      described by the school and in no case more than twelve (12) months.

                        1. For an applicant requesting cancellation more than three (3) business days after
                           signing the Enrollment Application or for a student completing no more than five (5)
                           percent of instructional time, no less than ninety-five (95) percent of tuition is
                           refunded. _____(Initial)

                        2. For a student completing more than five (5) percent but no more than twenty-five (25)
                           percent of instructional time, no less than ninety (90) percent of tuition is refunded.
                           _____(Initial)


                        3. For student completing more than ten (10) percent but not more than twenty-five (25)
                           percent of instructional time, no less than seventy-five (75) percent of tuition is
                           refunded. _____(Initial)

                        4. For student completing more than twenty-five (25 percent but no more than fifty (50
                           percent of instructional time, no less than fifty (50) percent of tuition is refunded.
                           _____(Initial)

                        5. For a student completing more than fifty (50) percent of instructional time, the school
                           is not required to issue a refund. _____(Initial)

                   f.   The school has adopted a policy for addressing extenuating circumstances such as
                        student injury, prolonged illness or death, or other circumstances that make completion of
                        the course or program of student impractical. The policy establishes a process for
                        determining a settlement which is reasonable and fair to the student and the school.
                        _____(Initial)

                   g. In the event that the school cancels or changes a program of study in such a way that a
                      student who had started the program is unable to complete it, arrangements are made in
                      a timely manner to accommodate the needs of each student enrolled in the program
                      affected by the cancellation or change. If the school is unable to make alternative
                      arrangements which are satisfactory to both the school and the student the school
                      refunds all money paid by the student or financial institute for the program. Similarly, if
                      the school cancels or changes the time or location of a course in such a way that a
                      student who had started the course is unable to complete it, the school refunds all money
                      paid by the student or financial institute for the course. All refunds will be made within
                      forty-five (45) days. _____(Initial)




I HAVE READ AND FULLY UNDERSTAND THE TERMS AND CONDITIONS OF THE FINANCE POLICY OF NV
ENTERPRISES TRAINING ACADEMY.
STUDENT’S NAME:                                                                                                     DATE:




                              ATTENDANCE, CLASSES & CLINICAL POLICIES

                                                      TERMS & CONDITIONS
NV Enterprises Training Academy primary purpose is to provide quality training that will assist the student with the ability to attain a position in the
work place in his/her chosen career. Aspects of the workplace rules, ethics, and regulations are emphasized in the program. Scheduled class time
provides an opportunity for student to demonstrate personal responsibility at the work place; therefore, instructors maintain attendance and tardy for
each course.

ATTENDANCE:                   There are no exceptions to the following policies:

                                              Student is allowed one (1) day of absence.
                                              Any additional absences must be made up.
                                              Student must call the school if they are going to be absent.
                                              Extensive absences may result in dismissal from the school.
                                              If the student is dismissed from school none of the described refund policy will apply.
                                              When student returns to class, they must consult with the Instructor for make-up work and/or make-up
                                               date(s).
                                              Student must complete all required hours and lessons in order to qualify for graduation.

TARDINESS:                    There are no exceptions to the following policies:

                                  If arriving 30 minutes late, no student will be allowed in class without a signed tardy slip from the office.

                                  If a student is late less than 30 minutes he or she must make up the part of the class that was missed.

                                  If a student is late more than 30 minutes he or she must make up the entire class.

                                  Extensive tardiness and leaving class early may be grounds for dismissal.

                                  Three (3) tardy equals one (1) absent day
                                  Students absent three (3) or more days will be placed on probation.

                                  If a student knows they are going to be late or absent, must call the school’s administration office at (770) 957-1558
                                   and leave a message for Valencia Flegler the Program Coordinator.


MAKE-UP CLASSES & EXTRA ASSIGNMENTS:

                              When student are required to make up a class and complete extra assignments, they must ask their instructor for their
                              assignments and the classes they must take.

CLASS MATERIALS:              Each student is responsible for the up keep of his or her own curriculum, etc. Books must be brought to each class
                              session. If you loose your books you must Purchase new ones.

TEST:                         No test or exam will be given unless student has completed the required segments of each program. Student must arrive
                              on time in order to take any test or exam. Only one make-up test or exam is allowed per lesson or program. Student
                              must consult with their instructor for the requirements and date of their make-up test or exam.

CHEATING:                     Any cheating during a test of any kind will be grounds for dismissal from the school, including but not limited to: talking,
                              discussing or reviewing any items on the exam with anyone else during the exam; consulting test-books or notes.


COMPLAINTS:                   Procedure and instructions for filing a complaint is posted on the school’s bulletin board. A copy can be obtained at the
                              administrative office.


GRADES:                       The following grading system will be used in all courses a grade of 75 or better is required to pass the training program.
                         A-   90-100
                         B-   80-89
                         C-   75--79
                         F-   74 below




ATTENDANCE, CLASSES & CLINICAL POLICIES - Cont’d


SEXUAL ABUSE:            Absolutely no sexual abuse in any form will be tolerated and is cause for instant dismissal.

UNIFORM:                 Uniforms must be worn at all times. White shoes or sneakers with rubber soles, name tag and watch with second hand
                         must also be worn at all times. Shoe must fit properly, be comfortable and keep clean. Your uniforms must also be kept
                         clean and wrinkle-free each day. The color and design of your undergarments should not be visible beneath your uniform.

JEWELRY:                 Jewelry harbors germs and it must be kept to a minimum. Sharp stones and settings can also injure a patient/resident
                         and tear gloves. Only simple jewelry should be worn. Small stud-type pierced earrings also reduce your risk of injury
                         from an earring being pulled or caught. Some facilities only allow a watch and wedding band.

PERFUME/COLOGNE:         Should not be worn when attending the Nursing Home or Hospice. Some patients/residents have allergies to different
                         fragrances. Some who are nauseated or have other medical problems may become ill from the scent of cologne. Others
                         with respiratory problems may have difficulty breathing with a heavy fragrance in their room.

HAND HYGIENE:            In the health care facilities special attention is given to Hand Hygiene. Many infections are spread on the hands in a
                         health care facility; therefore, you will be not permitted to wear artificial fingernails of any type, including nail tips, overlays,
                         silk wraps, gels, sculptured, or acrylic nails. Long nails (beyond the fingertips) are also not permitted. Keep natural nail
                         tips less than ¼-inch long. Chips and cracks in nail polish also hide germs, therefore nail polish is also not allowed.

PERSONAL COMMUNICATION DEVICES:

                         The use of personal communication devices, such as cell phones and pagers is not permitted in class or during your
                         clinical. Such communications devices must be set on silent alert and make your return phone calls only during your
                         breaks.

CLINICAL REQUIREMENTS:

                        Balance must be paid in full prior to clinical placement.
                        Student must attend the Orientation meeting at the clinical location. The date will be determined by the facility and
                         instructor.

                         No student will be allowed to leave the clinical area without approval from the instructor and/or the nursing supervisor of
                         the clinical facility.

                        No Student should be socializing or standing around the nurse’s station.

                        Along with the school’s insurance, each person is highly encouraged to carry their own liability insurance. There is a
                         small fee of $31.00. Please contact the administration office for details.

                        You must have proof of immunization on the approved State of Georgia form, negative TB, and background screen before
                         attending any clinical at the training facility. (Please note that a negative background screen may hinder your
                         employment opportunities. i.e. abuse, theft, assault and/or battery or other violent behavior.) _____(Initial)

                        Clinical make-up days must be completed with the next scheduled training class. If the student does not complete
                         the make-up clinical days the student grade of “I” will be converted to fail and the student will have to repeat the training
                         program. _____(Initial)



I HAVE READ AND FULLY UNDERSTAND THE TERMS AND CONDITIONS OF THE ATTENDANCE, CLASSES & CLINICAL POLICIES OF NV
ENTERPRISES TRAINING ACADEMY




STUDENT’S NAME:                                                                                                             DATE:
1.   Student's Name ___________________________                                                        Date___________________

     Success at NV Enterprise Training Academy (NVETA) requires a strong commitment on the part of students and staff. Students
     who are selected to attend NVETA have chosen to "go the extra mile" and to live up to expectations that are far beyond those
     for a typical healthcare training program.

     For students who are fully committed, the school's staff also makes promises. To partner for success, and students should
     commit to the following promises and should indicate at least one other item at the bottom of this page that will help lead to the
     student's success at NVETA.

2.   Students promise to be actively involved in their own education by:

             a.   Attending every class, every day, reviewing your educational materials daily and being on time.
             b.   Being responsible for your own actions and building personal standards of behavioral and training excellence.
             c.   Communicating directly with instructors and staff with concerns and even in the face of disagreement with teachers
                  and staff promising to comply with plans and consequences.
             d.   Proactively monitoring your own progress, communicating progress with your instructor at the first sign of trouble
                  and to help create a plan for recovery and success.
             e.   Recognizing that if school efforts at recovery fail and you end up failing more than one class this may be a sign that
                  you should consider additional resources to help you succeed.
             f.   Remembering that primary responsibility for your success lie with you as you make your way to
                  becoming a successful healthcare worker in a successful healthcare environment. _____(Initial)


3.   The student also agrees to:

             a.   I am aware of my responsibility to maintain the confidentiality of any and all information that I may come in
                  contact with and or have access to while in training. I am also aware that I am responsible for legal penalties
                  which may be assessed for unauthorized disclosure. _____(Initial)
             b.   I authorize NVETA to display or utilize in any of its published materials including photographs, videos, and
                  testimonials, pertaining to my training while attending school or following my graduation. I will not receive any
                  form of compensation to include fees or royalties for any such display. _____(Initial)
             c.   I agree to report any pregnancy prior to my participation in any clinical experience. I understand that the nurse
                  assistant training program is a very strenuous and could result in harm to my unborn child and myself. I release
                  NVETA responsibility if I chose not to disclose my pregnancy to the school officials. _____(Initial)
             d.   I have been given the opportunity to ask questions relating to academic progress, attendance policies, conduct
                  standards, dress code and instructional time schedules. _____(Initial)


4.   The school promises to be actively involved in students' training by:

             a.   Caring about our students and communicating that care by remaining true to our mission statement and to the
                  development of the student in the characteristics of the ideal NVETA graduate.
             b.   Working with students to develop plans for training recovery in the event of struggle.
             c.   Returning phone or email communication initiated by students or families within 24 hours.
             d.   Constantly working to refine our instructional and caring skills to become a premiere healthcare training school.

     I have read, questioned, and fully understand, and agree to abide by the conditions of entrance requirement in the Student
     Handbook.




Student Signature _______________________________________                                                    Date ____________


School Representative Signature ___________________________                                                 Date ____________
                                                 PROGRAM AND PAYMENT ACKNOWLEDGEMENT



 DATE OF APPLICATION:                                                                Account ID. :


 Start Date:                                                                         Graduation Date:

 NAME (LAST NAME FIRST)                                                                 PHONE NO.                        CELL NO.
                                                                                        (      )                         (    )
 PRESENT ADDRESS, HOUSE NUMBER & STREET


 CITY                                                        STATE                                               ZIP CODE


 Please Indicate the Class        Please Indicate Full-time or Part-time:                                                Please indicate the hours:
 are you Registering For:
                                          □ Full-time
                                          □ Part-time
                                                          PAYMENT SCHEDULE
 WIA STUDENT                      Length of Program:                        Application Fee:               Tuition Amount:

 CASH STUDENT                                                           Your weekly payments of $ _________ are due on Fridays by 4:00 pm
                                                            TERMS OF STUDENT LOANS
 Annual Percentage Rate:          Finance Charge:                       Amount Financed:                 Monthly Payments       Number of
                                                                                                                                           Payments
                   %              $                                         $                                    $


                 Amount Paid
  DATE         (Including Down                                    PAYMENT UPON REGISTRATON                                                 BALANCE
                  Payments)

               $ 200.00
                                      □    WIA-Funded                □ Check/Money Order             □    Cash       □ Visa/Mastercard    $
               (Non-refundable)       □    Student Loan
                                                                        Check No.:



  Total        $                  Credit Card #                                                                         V-Code #
 Amount                           Exp. Date:
  Paid                            Signature:


                                                        ITEMS RECEIVED UPON REGISTRATION
  □   Uniform: Size:                        □ Books                                                                     □    Test Registration Form
  □   Stethoscope (WIA)                     □ GA Evaluation Form                                                        □    GA Nurse Aide Handbook
  □   Blood Pressure Cuff (WIA)

WEEKLY PAYMENTS: I UNDERSTAND THAT ALL WEEKLY PAYMENTS ARE DUE EVERY FRIDAY AND THAT ANY PAYMENTS NOT RECEIVED BY
FRIDAY 4:00 PM WILL BE ASSESSED A 5% LATE FEE ON THE REMAINDING BALANCE. I FURTHER UNDERSTAND THAT MY FINAL PAYMENT MUST BE
PAID IN THE FORM OF CASH, CREDIT CARD OR MONEY ORDER. PERSONAL CHECKS THAT ARE RETURNED FOR INSUFFICIENT FUNDS I WILL BE
CHARGED AN ADDITIONAL $50.00. I ALSO UNDERSTAND THAT IF PAYMENT IS NOT PAID IN FULL BY COMPLETION OF THIS COURSE, I WILL NOT
BE ALLOWED TO TAKE MY FINAL EXAMINATION; GRADUTE WITH MY CLASS; OR RECEIVE A CERTIFICATE OF COMPLETION. I FURTHER
UNDERSTAND THAT I WILL ALSO BE ASSESSED A LATE PAYMENT PENALTY OF $25.00 WHICH ALSO MUST BE PAID PRIOR TO TESTING AND
GRADUATION.



STUDENT SIGNATURE:                                                                                       DATE:



SCHOOL REPRESENTATIVE SIGNATURE:                                                                         DATE:

				
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