Enrollment Applications | Northwest Care Academy

Applicant Information

Full Legal Name

Social Security Number

Email Address

City

Date of Birth required

Phone Number

Current Address

State / ZIP

Oregon Residency

Have you lived in Oregon for the past five (5) years?

Yes

No

If No, please list previous address(es):

Emergency Contact

Emergency Contact Name

Emergency Contact Phone Number

Relationship

Program Information

Program Applying For:

CNA

CMA

Education:

Desired Start Date required

Additional Questions

Can you read and write English?

Yes

No

Do you have reliable transportation to attend class and clinicals?

Yes

No

How did you hear about Northwest Care Academy?

Can you commit to the full 4-week program Monday-Friday?

Yes

No

If No, please explain:

Background Questions

Please answer each question honestly. A 'Yes' answer does not automatically deny admission; eligibility is determined through the required background check and drug screen process.

Have you ever been convicted of a felony?

Yes

No

Have you ever been found responsible for abuse, neglect, or exploitation of a child, elderly person, or vulnerable adult?

Yes

No

If you answered Yes to any question above, please explain:

Have you ever been convicted of a misdemeanor?

Yes

No

Applicant Acknowledgments

I understand a $150 non-refundable application fee is required to submit this application. This fee reserves my seat and will be applied toward my tuition if I am accepted into the program.

I authorize Northwest Care Academy to conduct a criminal background check as part of the admissions process.

I understand acceptance into Northwest Care Academy is contingent upon successfully passing the required criminal background check and drug screen.

I understand additional enrollment documents must be completed prior to the first day of class

I certify that all information provided on this application is true, accurate, and complete.

Application only. Enrollment agreement, payment plan, catalog acknowledgment, and other required documents are completed separately after application review.

Applicant Signature

Applicant Printed Name

Applicant Signature

Date required

Fill out this application form

Applicant Information

Oregon Residency

Emergency Contact

Program Information

Additional Questions

Background Questions

Applicant Acknowledgments

Applicant Signature

get started

971-375-3131

nwcareacademy@gmail.com