Certified Nursing Assistant (‘CNA’) Application Form Class Session applying forMay 17 Start, 10 Weeks, Mon-Fri, 6 p.m.-9 p.m. Application Fee of $100 is non-refundable*Application fee will be applied towards Tuition. Please make check or money order payable to:"CompassCare Institute of Caregiving" or Call Us at (203) 951-1189 for a credit card payment General Information: Full Name Social Security # Your Birth Date Address: Phone: Email Highest Education Level: Other Certifications, if any: Have you ever been known as another name?YesNo If yes, please indicate Do you have any medical conditions that in any way impairs your ability to practice your profession with reasonable skill and safety?YesNo If Yes, please explain Personal Statement (Essay): Please limit your essay to 300 words. Choose one of the following topics for your essay: Why do you want to be a CNA? How will you use this important certification in your career? Describe your commitment to the field of caregiving and serving others (including your dedication to doing whatever it takes in serving your existing or potential clients). For example, working beyond 9 am to 5 pm and working weekends. Why would you like to attend CompassCare Institute of Caregiving?