CNA Application (VA)

First Name

Last Name

Personal Email Address

City

County

Choose the county where you live

State

Phone Number

What is the best way to contact you?

How did you hear about the Frances Marion Manor/Smyth County Community Hospital Nurse Aide Training Program??

Are you a US Citizen?

Are you a Permanent US Resident?

Have you ever been discharged from a job?

If yes, please explain

Have you been convicted of a crime?

If yes, please explain

Class dates you are interested in

I understand this class is an person class that requires me to attend the program campus in Marion, VA .

Have you ever been employed by Ballad Health?

Are you currently employed by Ballad Health?

If yes please provide team member number, facility and unit or area where you worked, and if your name at the time of employment with Ballad Health.

If chosen to attend this course, do you plan on applying to work at Ballad Health as a CNA?

Are you currently enrolled in a Nursing program?

If you are currently enrolled in a Nursing Program, have you completed the first semester, including Fundamentals of Nursing?

High School

Year Graduated

Current or most recent employer

Supervisor

Reference 1

Phone Number

Email Address

I have read the Consent Agreement

Consent Agreement: I certify that the forgoing representations are true and correct to the best of my knowledge. I voluntarily release from liability and/or damages all parties who may issue or receive information regarding my character, previous employment, or scholastic record that may concern my application for consideration by Ballad Health involving their Nurse Aide class. It is my understanding that Ballad Health will make a thorough investigation of my work and personal history and my verify all data given in my application for their Nurse Aide Class, related papers, or oral interviews. I authorize such investigation and the giving and receiving of any information requested by Ballad Health and I release from liability any person giving or receiving such information. I understand that falsification of data given or other derogatory information discovered as a result of this investigation may prevent my being accepted into the class. If accepted, I will accept and abide by all rules and regulations governing the class. These rules do not constitute a contract of employment and I do not construe them as much. If requested by the management at any time, I agree to submit to search of my person and I hereby waive all claims for damages on account of such examination. I am responsible for necessary transportation to and from class and clinical areas. I understand that nothing contained in this application or in the granting of an interview is intended to create an employment contract between Ballad Health and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon Ballad Health. I understand that if accepted into this class, policies and rules that are issued are not conditions of employment and that the facility may review policies or procedures, in whole or in part, at any time. A copy of this authorization may be accepted with the same authority as the original. Selecting Yes serves as your digital signature

Today"s Date

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