Right Choice Health Care Training Institute, LLC
2301 Hurstbourne Village Drive, Ste 200
Louisville, KY 40299
502-974-2541
Application & Enrollment Form
Date today: ______I am registering for the class that begins: ______
Circle One: Day Week End
PERSONAL INFORMATION:
Name
Last First Middle/Maiden Social Security Number (required)
Contact Information
Home phone Cell Phone Emergency Phone
What is your E-Mail address? ______
Address
Number & Street City State Zip
How long have you lived at the above address? ______
Previous Address
Number & Street City State Zip
How long at this address? ______
How did you first hear about our program? ______
Do you have a latex allergy? (circle one) Yes No
The profession of Nurse Aide requires certain physical characteristics of strength and stamina. Please initial each blank below, indicating that your ARE ABLE to perform the task indicated.
_____ I am able to be on my feet for up to 12 hours at a time
_____ I am able to stoop, bend, lift and twist without difficulty
Is there any reason why you would be unable to perform or to perform safely any duties of the position of Nurse Aide, such as transferring patients from bed to chair or to the bathroom? YES NO
If yes, please explain.
Right Choice Application and Enrollment Form Page 2
EDUCATION:
Have you completed high school? Yes No ______
Name of High School (include city and state)
Have you completed college? Yes No ______
Name of college attended (include city and state)
If yes, date of graduation and name of degree: ______
Are you a nursing student? Yes No
If yes, what school do you attend?
Please list any other education/certificates/licenses/training etc. you have received.
_____ (Initial Here) I understand that if I do not meet the minimum 75 hour (59 classroom/16 clinical) attendance requirement I will not be issued a certificate of completion.
_____ (Initial Here) Right Choice Health Care Training Institute, LLC. Is an educational institution and does not make any guarantees regarding your ability to procure employment upon completion of our program.
Student Protection Fund
KRS 165A.450 requires each school licensed by the Kentucky Commission on Proprietary Education to contribute to a Student Protection Fund which will be used to pay off debt incurred due to the closing of a school, discontinuance of a program, loss of license, or loss of accreditation by a school or program. To file a claim against the Student Protection Fund, each person filing must submit a completed “Form for Claims Against the Student Protection Fund”. This form can be found on the website at www.kcpe.ky.gov.
Authorization to check information on this application.
I certify all information on this application to be true and that nothing asked for has been omitted. I understand that any material omission or misrepresentation will be sufficient cause for dismissal from the Nurse Aide training program with no refund of any funds already paid to the school.
I authorize Right Choice Health Care Training Institute, LLC to conduct a criminal background check as well as other background checks required by the state of Kentucky for admission to this program and release Right Choice from any and all liability and responsibility arising from their doing so.
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Applicant signature Date
______
Interviewer signature Date
Right Choice Application and Enrollment Form Page 3
REFUND POLICY.
In order to register for a class you must submit in person a completed enrollment form along with a NON-REFUNDABLE $50.00 registration fee. Classes are filled on a first come first served basis. A $50.00 registration fee will hold a seat in the class of your choice up to 7 days prior to the first day of class. To continue to hold a seat a second payment of $400.00 is required 7 days prior to the first day of the class for which you are enrolled. Reserved seats for which the full $450.00 dollars is not received 7 days prior to the first day of class will be opened up to other students.
The final balance of $140.00 must be paid in full before the clinical portion of the class. Any students not paid in full by the clinical portion of the class will not be allowed to participate in the clinicals and will not complete the class. Scheduling a make up clinical session for any student for non-payment is done at the discretion of Right Choice once payment is made and is dependent on class offerings and an open seat in a clinical session.
Tuition refunds (less the $50.00 registration fee) will be available up to 7 days prior to the first day of class in which the student is enrolled. After that date, there will be no refunds. Students who are dismissed due to improper conduct, absences or who fail to achieve competency are not entitled to any refunds. Students who do not attend the minimum required number of hours due to absences or tardiness are not entitled to any refunds. Students who drop the class for personal reasons are not entitled to any refunds. Student who do not complete the class due to non-payment are not entitled to any refunds.
Any student who fails the background check or drug screen is eligible to be refunded any tuition paid (less the $50.00 registration fee) as long as all supplies issued to the student are returned in “new” condition. The cost of any supplies not returned in “new” condition will be deducted from tuition paid and student will be issued a refund for the difference. The cost of the supplies issued are as follows:
Textbook/workbook/CD - $80, Binder - $5, Scrub top - $12, and Right Choice Bag - $10
Right Choice Health Care Training Institute, LLC reserves the right to cancel any class due to low enrollment and refund all funds paid by the student.
I have read and understand the REFUND POLICY of Right Choice Healthcare Training Institute
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Applicant signature Date
______
Printed Name
______
Interviewer signature Date