MNA Program Application / MNA Pre-Test

student
First Name MI
Last Name
Mailing Address
Apt./Suite Number
City
State
Zip Code
Home Phone
Cell Phone
Social Security #
Email
Birth Date (mm/dd/yyyy)
Are you a US Citizen ?   Yes: No:

Is English your primary language?   Yes No
Do you have a documented disability that you would like us to be made aware of? (ADA Accommodations or other)    Yes: No
What school did you attend for your LNA training?  
Do you hold a valid, unencumbered New Hampshire LNA license? :    Yes: No:

 

Have you been employed as an LNA in NH within the past 5 years for the hours-equivalent of 2 years of full time employment? :    Yes: No:
(per NUR 802.01b)   (Equivalent to 3,744 hours)

 

Have you EVER been convicted of a Violation, Misdemeanor or Felony ? :    Yes: No:

*Please note, Criminal Record checks are conducted on all of our students. Falsifying information on this application can result in termination from the program.

 

Emergency Contact Name
Emergency Contact Phone
Emergency Alternate Contact Phone
Applicant Essay.
Please describe your hopes, desires and goals as pertaining to becoming proficient in the administration of medications as a Medication Nursing Assistant. Please describe strengths you possess and how they may benefit those you serve as an MNA. This is an essay and requires more than just one or two sentences.  
How did you hear about us ?         

Are you being sponsored by a Facility? :    Yes: No:

I would prefer to take a :        
Start Date:
Enter preferred location of training:

I CERTIFY THAT ALL INFORMATION PROVIDED HEREIN IS TRUE AND COMPLETE. I also certify that I have read the requirements, attendance, refund and criminal record policies. I agree to the terms and am able to FULLY meet the requirements of LNA Health Careers and Nur 802.03 (duties of students).   The information provided by the applicant on this application form will be held confidential unless requested by the NH Board of Nursing. LNA Health Careers reserves the right to deny admission to any application, within the judgement of the Medication Nurse-Reviewer. Once accepted a photo ID is required to attach to your application for our file. [Per RSA188-D:23 "Any (student) may cancel this transaction any time prior to midnight of the third business day after the date of this transaction".]

 Please check this box if you agree to the preceding terms and conditions. By checking this box you are electronically signing that you have read and understand the refund, attendance & criminal record policies, that you can meet the essential requirements and that you agree to all said terms and conditions.