Easterseals CNA Classes Application
Personal Information
First Name
Last Name
Date of Birth
Primary Phone Number
Best Time to Reach You
Address 1
City
State
Zip Code
Email
Are you willing to undergo and successfully complete a background check as required for CNA certification?
Yes
No
All CNA students are required to complete a two-step TB test and a physical examination before starting class. If you are accepted, do you agree to undergo these tests and submit the required documentation by the specified due dates?
Yes
No
Educational Information
Highest Level of Education Completed
Please select...
Less than High School
High School Diploma
GED
Some College
Associate Degree
Bachelor Degree
Graduate Degree
Other
If you chose 'Other', please explain
Do you have a high school diploma or GED?
Yes
No
High School
Easterseals Affiliation
Do you currently receive services from Easterseals?
Yes
No
Please describe the services you receive and your involvement with Easterseals.
Have you ever been employed by Easterseals?
Yes
No
Please describe Job Titles you hold/held and your length of employment:
Scholarship Determination
Are you applying to receive funds to help pay for a portion of CNA class costs?
Yes
No
Do you have financial reasons for requesting a scholarship?
Yes
No
Financial Needs Assessment
Employment Status
Please select...
Full-Time
Part-Time
Unemployed
Student
Retired
Monthly Household Income Range:
Please select...
Less than $1,500
$1,500 - $2,999
$3,000 - $4,999
$5,000 - $7,499
$7,500 or more
Number of People Supported by Your Income
Do you currently receive public assistance?
Yes
No
Please describe the public assistance you receive:
Please explain why you are applying for this scholarship and how it could benefit your life.
Essay Questions
In a detailed essay, please explain why you are looking to embark on a Certified Nursing Assistant certification.
In a detailed essay, please explain your future career and/or educational goals.
In a detailed essay, please explain your strengths and weaknesses and how you will leverage them to successfully complete the Certified Nursing Assistant program.
Employment History
Resume/Employment Information
Are you currently employed?
Yes
No
Current/Most Recent Employment
Company
Position
Start Date
End Date
Previous Employment 1
Company
Position
Previous Employment 2
Company
Position
Contact Information