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admission > step 1
PLEASE READ: Space labeled (*) indicate required information that you the applicant must provide. All information must be correct in order
for us to process your application successfully. Each applicant should submit one application; multiple application by the same applicant
can reduce processing time. Please allow 2-3 business days for a representative to contact you (either by phone or email) to confirm your
application. If you have any questions regarding this application or anything else please call us at (301) 853 -9100 or email
us at cambridgetocna@verizon.net. Thank you.

____________________________________________________________________________________________________________________________________

ENROLLMENT AGREEMENT

Last*


First
*


Middle I.N


SSN
- -

Date of birth (mm/dd/yr)*

sex
*


Home #* Work # Cell # Email

Street address*

City* State* Zip code*

Enrollment date/ class time
I am enrolling at the Cambridge Nursing Academy for Certified Nursing Assistant program of 120 hours.
The program is scheduled to begin and conclude on:
*


I prefer to attend following class time:
*

Please read and verify the following
Upon successful completion of the Program, I will receive a Certified Nursing Assistant Certificate.
Graduation requirements:
- Maintain an 80% attendance rate in the classroom
- Maintain a 100% attendance rate for clinical portion of the program
- Maintain a grade of 80%
- Satisfy all financial obligations

Note: Student must achieve a grade of 80% or above in classroom and lab skills performance by the end of the classroom portion.
Refunds will be awarded to students who do not complete program, according to the refund policy. Cambridge Nursing Academy
acknowledges that job placement and job salaries cannot be guaranteed.



Payment Schedule:
- First installment is due upon finalizing registration.
- Second payment is due two weeks after first payment.
- Last payment is due after fourth weeks in school.

Refund Policy:
1. All monies paid by students will be fully refunded if the student chooses not to enroll in or to withdraw from the school within
seven calendar days after having signed the enrollment contract.

2. If the student chooses not to enroll after the seven-day cancellation period, but before the first day of instruction, the school
will retained the registration fee.

3. If after the seven-day cancellation period, a student withdraw or is terminated after the instruction begin, refunds will be made
according to the following proportion of total program taught by date of withdrawal:

4. If a school closes, cancels or discontinues a course or program, the school will refund to each current enrolled student all
monies paid by the student for tuition and fees and monies for which the student is liable for tuition and fees.

5. Students are requested, but not required, to notify the Director or designated school official if they are withdrawing from school.

6. Refund is based on the last date of attendance.

7. All refunds due will be paid within 60 days of the student last day of attendance.

5. Books purchased are the property of the student and are not refundable, except within the seven-day cancellation period.

I have read and understand the information listed above. *

__________________________________________________________________________________________________________________


REGISTRATION FORM


Have you attended this course before?


Have you ever filled an application with us?


If no, how did you learn about us?

Under penalties of perjury, I affirm that the preceding information is completed and correct. *

__________________________________________________________________________________________________________________


STATEMENT OF HEALTH

Good physical, mental and emotional health is necessary to complete the clinical rotation of the Nursing Assistant course.
Please check the appropriate paragraph below.


I am in good health and am not aware of any physical, mental, or emotional limitations that would interfere with my clinical
responsibilities as a Geriatric Nursing Assistant.


If yes please provide the detials of your limitations:




__________________________________________________________________________________________________________________


CONFIDENTIALITY STATEMENT

Patient Confidentiality:
1. All information learned during a patient care experience or from patient records is completely confidential.
(Exceptions: Clinical Instructors and Program faculty may be notified of all confidential matters).

2. No comment should be made about the patient which could be taken as negative or critical. Such comments could easily
be mistaken by the patient or family if overheard. The attitude taken about the patient and the treatment should always
be in the best interest of the patient.

Confidentiality Agreement:
I understand and agree that in the performance of my duties as a Nursing assistant student in the Program, I must hold patient
information in confidence. Further, I understand and agree that intentional or voluntary violation of the patient’s confidentiality
may result in refusal of the clinical site to allow me to continue to participate in learning experiences there. Violating Patient
confidentiality may result in failure to meet course objectives.

I have read and understand the information listed above. *

__________________________________________________________________________________________________________________

CREDIT CARD/ PAYPAL ACCOUNT INFORMATION

The following information is intended to match your registration information with the PayPal website. All payment transaction
are made with PayPal either with a credit card or a PayPal account.

Payment method

Name of card/ PayPal account holder *

If you paying with a credit card provide the following:

First and last 4 digits * - xxxx - xxxx -

Expiration date(mm/dd/yr) *


*Before submiting, please check your information to make sure that you have provided the right information.
Click continue to submit form and proceed to step 2.