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.

March 4 - 28 (Day) M,T,Th,F 7AM - 3:30PM

Continue to Step 2

Choose a class:

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

	April 29 - May 23 (Day) M,T,Th,F 7AM - 3:30PM
	August 5 - 29 (Day) M,T,Th,F 7AM - 3:30PM

Continue to Step 2

Choose a class:

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

	February 25 - March 7 (Evening) Bridge Course Participants Only: M-F 4PM - 9PM
	March 11 - April 19 (Evening) M,T,Th,F 4PM - 9PM ( This class is full, but you can still apply and be added to our waiting list)
	April 22 - May 31 (Evening - Weekday & Weekend Combo) Class will meet 5PM - 9PM 4/22-4/24, 5/1-5/3, 5/6-5/8, 5/14-5/17, 5/20-24, 5/28-5/31 and from 2PM -10:30PM 4/27, 4/28, 5/11, 5/12
	May 28 - June 7 (Evening) Bridge Course Participants Only: Class will be held May 28 - May 31 and June 3 - 7 from 4PM - 9PM
	June 10 - 28 (Day) M-F 7AM - 3:30PM
	July 1 - 26 (Day) M,T,Th,F 7AM - 3:30PM
	August 5 - 29 (Day) M,T,Th,F 7AM - 3:30PM
	September 3 - October 11 (Evening) M,T,Th,F 4PM - 9PM (Class will be held W 9/4)
	October 14 - 24 (Evening) Bridge Course Participants Only: M-F 4PM - 9PM
	October 21 - November 14 (Day) M,T,Th,F 7AM - 3:30PM
	November 25 - December 19 (Day) M,T,Th,F 7AM - 3:30PM

Continue to Step 2

Choose a class:

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

	March 4 - 22 (Day) M-F 7AM - 3:30PM
	April 1 - May 10 (Evening) M,T,Th,F 4PM - 9PM (This class is full, but you can still apply and be added to our wait list.)
	June 10 - 28 (Day) Class only for Chippewa Falls High School (Summer)
	July 1 - 26 (Day) M,T,Th,F 7AM - 3:30PM and W 7/24
	July 29 - August 16 (Day) M-F 7AM - 3:30PM
	August 19 - September 30 Class only for Chippewa Falls High School (Fall)
	September 16 - October 10 (Day) M,T,Th,F 7AM - 3:30PM
	October 14 - November 14 (Evening) M-F 4PM - 9PM
	November 25 - December 19 (Day) M,T,Th,F 7AM - 3:30PM

Continue to Step 2

First Name:

Middle Inital:

Last Name:

Primary Phone:

Secondary Phone:

Address:

City:

State:

Zip:

Email:

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

Are you participating in the WisCaregiver Career Program?
Yes No

If yes, please enter your student ID

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

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: