Registration - Milagro Health Academy

Name

First

Middle

Last

Street Address

City, State, Zip

Phone Number

Email

Social Security Number

Are you at least 16 years of old?

Yes
No

Date of Birth

High School Graduate

Yes
No

Year

Ethnicity(Select One)

Emergency Number CNA

Have you ever been convicted of felony

Yes
No

if Yes, Please explain

Are you fluent in reading and writing English?

Yes
No

Do you understand that our CNA program is an accelerated program that requires you to be present Monday-Friday for three weeks, and independent studying outside class times?

Yes
No

Do you have reliable transportation to class and clinical site as assigned?

Yes
No

Do you have any prior experience in Healthcare? If yes, please describe.

Our CNA program requires a student to maintain an average grade of 70% or higher in order to be eligible for clinical placement and continued clinical rotations. Do you understand and accept?

Yes
No

Release of Liability and Assumption of Risk. I am enrolling as a student in a course offered by Milagro Health Academy. I understand that my training involves physical activities which have a risk of physical harm to me. I hereby release and forever discharge Milagro Health Academy, there employees, officers, directors, agents, and assigns, from any and all claims, demands, actions, causes of action, infuries, or suits of any kind or nature whatsoever resulting from my participation in the course of the study provided by MHA. I assume all risk of injury to myself while participating in the course of study. In addition, I represent that I have no physical limitations that would hinder nor render me unable to perform the physical activities in the course of study. I declare that the terms of this application have been completely read, fully understood.

Agree
Disagree

Emergency Contact

First

Last

Emergency Contact Phone Number

Please note a typed name is recognized as an acceptable and legally binding signature.

Consent
Do not Consent

Name

First

Last