ECA Application

Personal Information

First Name

Middle Name

Last Name

Preferred Name

Date of Birth

Email Address

Mobile Phone

Alternate phone

Address and Emergency Contact

Street Address

Address 2

City

State

County

ZIP code

Emergency name

Emergency relationship

Emergency phone

Emergency email

Program Selection

program track

CNA

If not selected for the first class, I would like to be considered for the next class

Yes No Please Contact Me to discuss

If offered, I would like the option to secure a future seat opportunity

Yes No Please Contact Me to Discuss

Why do you want to become a CNA?

Why are you applying to Elevate Care Academy?

Identification

Do you have two forms of identification? (Must have two to get accepted)

Yes No Pending Receiving

Your First ID type

State Driver's License State Identification Card Passport

Please upload Your first ID (Can take a picture)

Your Second ID Type

State Driver's License Social Security Card Passport

Please upload Your second ID (Can take a picture)

Compliance Readiness

Do you consent for a background check?

Yes No

Do you have TB documentation available?

Yes No Pending

Upload Your TB documentation

Is your Physical Documentation available?

Yes No Pendng

Upload your physical documentation

Academic Readiness

Highest level of education completed

High School (Equivalent) Vocational Some College College Graduate

I am prepared to complete a math assessment

Yes No

I am prepared to complete an English comprehension / reading assessment

Yes No

Tuition and Acknowledgements

I understand that tuition for the CNA program is $1,500

Yes

I understand that a $500 seat deposit may be required to secure a seat if accepted

Yes

I understand that a seat is not secured until any required deposit is received and confirmed

Yes

I acknowledge that $500 deposit is non refundable only able to transfers deposit to other class IF seat is available

Yes

School Policy and Student Guidlines

Required Review: View Policy Article | Download PDF

I acknowlege reading and understanding the ECA School Policy, Guidelines, and Classroom / Clincal Restrictions

Yes

Payment Option I choose

Paid in Full ($1,500.00)

Deposit ($500.00)

Deposit $500 and 4 Monday payments of $250 starting June 1 for May class

I certify that the information I have provided is true and complete

Yes

PayPal Payment

Complete Your PayPal Payment

Scan the QR code or click the button below to pay securely through PayPal.

Pay with PayPal

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