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Nursing Assistant/Home Health Aide Training Program Application – South Boston
Month
*
Class Start Date Preference
Classes
*
Day
Evening (Not currently available)
First Name
*
Middle Name
Last Name
*
Date of Birth
*
MM slash DD slash YYYY
Age
*
Last 4 of SSN
*
Gender
U.S. Citizen?
*
Yes
No
Country of Origin
*
Veteran?
*
Yes
No
Race
*
Check off those that apply
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Ethnicity
*
Hispanic or Lantino
Non-Hispanic or Latino
Street Address
*
City
*
---- Select State * ----
*
---- Select State * ----
Alabama
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District of Columbia
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
*
Primary Phone
*
Okay to text?
*
Yes
No
Secondary Phone
Okay to text?
Yes
No
Email
*
Emergency Contact
*
Phone Number
*
Do you have a disability?
*
Yes
No
Would you like to apply for SNAP?
*
Yes
No
Do you receive non-cash benefits?
*
Yes
No
Are you employed?
*
Yes
No
Looking for work?
*
Yes
No
Type
Full Time
Part Time
Multiple
Tenure
Day Labor
Permanent
Seasonal
Temporary
Are you currently in school?
*
Yes
No
Highest grade completed
Highest degree earned
License earned?
Yes or no; if yes please specify
Yes
No
License earned:
*
Are you currently pregnant?
*
Yes
No
Source(s) of income
Alimony/Child Support
Employer Disability
Employment
Military Allotment
Pension
Social Security
SSI
SSDI
SNAP
TAFDC
None
How did you hear about us?
*
Choose which one applies
Web Search
Friend or Family
Mass Rehab
STRIVE
DCF
DTA
Past Student
College
Employee
Catholic Charities Program
Hospital
Do you need support in any of the following areas?
Income/Basic Needs
Education/Employment
Heath/Wellness
Legal Issues
Transportation
Child Care
None
What do you know about being a nursing assistant and/or a home health aide?
*
Have you taken care of anyone who was ill? How was that experience? If not, how would you imagine it being?
*
Describe your job experience:
*
Describe a strength, something you do very well:
*
Describe a weakness, something you do not do very well (We ALL have them!):
*
Describe how you handled a difficult situation:
*
How do you manage stress? How do you take care of yourself?
*
What do you hope to get out of this program?
*
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