Dove Healthcare

CNA Course Application

Choose a location:

Dove Healthcare - Bloomer

Dove Healthcare - Osseo

Dove Healthcare - West Eau Claire

Dove Healthcare - Wissota Health & Regional Vent Center (Chippewa Falls)

Choose a class:

All registrations must be received by midnight on the Thursday before the class begins.

February 17 - March 23 (Day) M,T,W from 7am-3:30pm

Continue to Step 2

Choose a class:

All registrations must be received by midnight on the Thursday before the class begins.

June 1 - 25 (Day) M,T,Th,F from 7am - 3:30pm

Continue to Step 2

Choose a class:

All registrations must be received by midnight on the Thursday before the class begins.

	January 6 - 24 (Day) M-F from 7am - 3:30pm (This class is full, but you can still apply and be added to our wait list.)
	February 3 - 27 (Day) M,T,Th,F from 6am - 2:30pm
	February 3 - March 13 (Evening) T,W,Th,F from 4pm - 9pm
	March 9 - April 2 (Day) M,T,Th,F from 7am - 3:30pm
	April 6 - May 15 (Evening) M,T,Th,F from 4pm - 9pm

Continue to Step 2

Choose a class:

All registrations must be received by midnight on the Thursday before the class begins.

	January 6 - February 10 (Day) M,T,W from 7am-3:30pm
	March 30 - May 4 (Evening) M,T,W,F from 3pm-9:30pm (This class is full, but you can still apply and be added to our wait list.)

Continue to Step 2

First Name:

Middle Inital:

Last Name:

Primary Phone:

Secondary Phone:

Address:

City:

State:

Zip:

Email:

Please check one of the following:

	I am interested in participating in Dove Healthcare's Train-to-Work Program, a no-cost option for the CNA class and state competency exam. This program requires an interview and 12 month work commitment as a CNA with Dove Healthcare.
	I am not interested in the Train-to-Work Program and will be using my own funds or 3rd party funds to pay the class fee and state competency exam.

At which facility would you prefer to work?

Dove Healthcare - Barron

Dove Healthcare - Bloomer

Dove Healthcare - Orchard Hills Assisted Living (Eau Claire)

Dove Healthcare - Osseo

Dove Healthcare - Rice Lake

Dove Healthcare - Rutledge Home (Chippewa Falls)

Dove Healthcare - South Eau Claire (Mall Drive)

Dove Healthcare - West Eau Claire (Truax Blvd)

Dove Healthcare - Wissota Health & Regional Vent Center (Chippewa Falls)

Where did you hear about this class?

Please specify

Add another referral source.

Where did you hear about this class?

Please specify

Add another referral source.

Where did you hear about this class?

Please specify

Are you applying to take this class in an effort to pursue an employment opportunity with Dove Healthcare?
Yes No

Are you applying to take this class to satisfy a program requirement (i.e. nursing school)?
Yes No

Emergency Contact Information

Contact Name:

Relationship:

Phone:

References

Name:

Relationship:

Phone:

Continue to Step 3

I verify that all the information which I have provided on this application and in resumes/exhibits is true, correct and complete. I understand that false, misleading, incomplete or omitted information will result in rejection of my application, whenever discovered. If my application is considered, I authorize an investigation and verification of all information and statements provided on this application. I release any and all persons or companies from any liability for releasing information or verifying statements on this application.

By signing and dating this form, I hereby swear all the above information is correct.

My typed first and last names below shall have the same force and effect as my written signature.

First Name:

Last Name:

Date:

Confirmation Code: