Nursing Assisting / Medication Aide Application

Nursing Assisting / Medication Aide Application
Name*

First NameMiddle/Maiden NameLast Name
Southern Union Student A# if applicable
Date of Birth:*

MonthDayYear
Phone Number*
Please enter a valid phone number.
Email*
student1@mail.suscc.edu
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Person to contact in case of emergency*
Emergency contact phone*
Name of Employer:*
Click HERE to view the

Nursing Assistant / Medication Aide Program Brochure
Course(s) desired:*
CNA Course Completion Documentation

Cancelof
Upload written permission from your employer to do clinicals with your employer:*

Cancelof
Semester applying for:*
Enter your preferred class start date:*

MonthDayYear
Course credit option:*
Which of the follwing best describes you:*

High school graduateCompleted GEDNone of the above
Name of High School and Graduation Year
Location and Year of GED Completion
Are you a US citizen?*

YesNo
State of Residency: Please check the appropriate box:*

I affirm that I have been an Alabama resident for at least the previous twelve (12) monthsI affirm that I have been a resident of one of the following reciprocal Georgia counties for at elast the previous twelve(12) months: Carroll, Chattahoochee, Coweta, Haralson, Harris, Heard, Marion, Meriwether, Muscogee, Pike, Quitman, Stweart, talbot, taylor, Troup, UpsonI am not a legal resident of Alabama or one of the above mentioned Georgia counties
Gender: (optional)

MaleFemale
Ethnic origin: (optional)

WhiteHispanicAmerican Indian / Alaskan NativeBlackAsian / Pacific IslanderOther
Please select which of the following best applies to you:*
Name of Employer:*
WIOA Contract Number*
WIOA Contact Person*
WIOA STUDENT NOTICE:

The WIOA scholarship will pay for all required program expenses. Students are responsible for purchasing all needed tools and supplies (book, background check, drug screen, uniforms, stethoscope, immunizations) upfront then submitting receipts for reimbursement.

Receipts for required out of pocket expenses should be submitted to Christine Cupp (ccupp@suscc.edu) in the Business Office on the Opelika campus for reimbursement within the the first two weeks of program start.

Please use the estimated CNA cost sheet as a reference.
It is the official policy of the Alabama State Board of Education and Southern Union State Community College that no person shall, on the grounds of race, color, disability, gender, religion, creed, national origin, marital status, or age, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program, activity, or employment. Persons requiring reasonable accommodations under the Americans with Disabilities Act (ADA) should contact the Southern Union State Community College ADA Coordinator at (334) 745-6437 extension 5351.
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