Application

All fields are required.

If they do not apply, please fill with N/A.  After completing this form please send your $35.00 (non-refundable) (Sorry NO personal checks or cash accepted) application/processing fee to:   Tennessee Health Careers, LLC 116 N 2nd St. Suite B10 Clarksville, TN 37040 Office: 931-648-2424 Fax: 931-648-2425 or click HERE to pay online. Click here for information on Transferability of Credits

Last Name:
First Name:
Middle Initial:
Street: City: State: ZIP:
Home Phone:
Cell Phone:
Your Email:

Date of Birth:

Are you a US Citizen?  Yes No Social Security Number:
GED or Highest Grade Completed?
Have you ever been convicted of a felony or misdemeanor? Yes No 
Are you listed on the TN Abuse Registry? Yes No 
Briefly describe event and date occurred:
Emergency Contact Name : Phone #:
Alternate Phone #:

Course Information:

Do you require any special accomodations because of physical condition or disablitity or learning condition or disability?:

   If yes, please explain
(required) Describe what you hope to achieve from this program:
I would prefer to take a: | or A Specific Date

How did you hear about us?:

(please list specific name)

I CERTIFY THAT ALL INFORMATION PROVIDED HEREIN IS TRUE AND COMPLETE.
I also certify that I have read the Refund and Attendance Policy and agree to the terms. I further acknowledge that Tennessee Health Careers may complete a criminal record check or Abuse Registry on me at any time during the program. If it is found that I have a criminal history not previously disclosed on this application, I may be in jeopardy of not being hired to work as a CNA, and I agree not to hold TN Health Careers responsible. The information provided by the applicant on this application form will be held confidential. Tennessee Health Careers reserves the right to deny admission to any application, within the judgment of the Program Coordinator. Once accepted a photo ID is required to attach to your application for our file.

 

"I understand I must complete all enrollment forms and present a valid photo ID in person at Tennessee Health Careers at least 5 days prior to the start of class, I understand I can not begin class until the enrollment forms have been completed. The application fee is non refundable"

(required) Please check this form for accuracy,
then check this box if you agree:
 I agree
and then sign and date here:

Type this code into the box: captcha Then Press:

At the conclusion of this form please send your $35.00 (non-refundable) (Sorry NO personal checks or cash accepted) application/processing fee to:   Tennessee Health Careers, LLC 116 N 2nd St. Suite B10 Clarksville, TN 37040 Office: 931-648-2424 Fax: 931-648-2425 or click HERE to pay online.