WHA Admission Application Form (1) Step 1 of 9 11% WISDOM HEALTH ACADEMY PAYMENT AGREEMENT CONTRACT Consent(Required) I agree to the privacy policy.I agree to pay the full tuition one week before class ends, As outlined in the school catalog while enrolled in the school, I understand that my financial obligation to the school must be paid in full before a certificate of completion may be awarded.PAYMENT PLAN Option (Morning Class/Evening Class) Scheduled Payment Dates Amounts # 1 Registration Payment Due before registration has been completed $355 Registration fee Second payment for the Nurse Aide 1 Class Due before the end of in person lab training $355– Half of tuition due Third payment for the Nurse Aide 1 Class Due before the end of clinical rotation $355– Final tuition payment Paid In Full : $1,065 Total balance must be paid before class endsStudent Name(Required) First Last must sign agreement(Required)Date(Required) MM slash DD slash YYYY ADMISSIONS APPLICATION Wisdom Health Academy 3622 Shannon Road Suite 103 Durham, NC 27707 (919) 908-9939 Instructions:Respond to all questions. Use your legal name, complete form in its entirety. Nurse Aide 1 Program ENROLLMENT DATE:Start Date(Required) MM slash DD slash YYYY End Date(Required) MM slash DD slash YYYY PERSONAL INFORMATION: Answer all questions.Name(Required) First Middle Last Current Address City State / Province / Region ZIP / Postal Code Telephone #:(Required)Email(Required) Gender(Required) Male Female Other Age(Required)Please enter a number from 15 to 99.Date of Birth(Required) MM slash DD slash YYYY Race(Required)American Indian / Alaska NativeAsianBlack / African AmericanWhiteHispanic / LatinoOther / Unknown / MultipleEmergency Contact (to be notified in case of emergency):Indicate you're highest Education Level Completed(Required) High School Graduate Adult High School Vocational Diploma Associate Degree Bachelor’s Degree Master’s Degree or Higher Select AllHigh School InfoName of Last High School(Required)Address(Required) City State / Province / Region AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Start Date(Required) MM slash DD slash YYYY Last Date of Attendance:(Required) MM slash DD slash YYYY Did you graduate from High School?(Required) YES NO Month of:(Required)of the year(Required)I received an Adult High School DiplomaI received a GEDRESIDENCY INFORMATIONU.S. Citizen?(Required) YES NO Status(Required) Resident Alien: Refugee Asylee Visa North Carolina Legal Resident(Required) YES NO Indicate Place of previous residence(Required)Have you been convicted of a crime?(Required) YES NO Describe in full.(Required)PERSONAL / PROFESSIONAL REFERENCE does not include family members or past supervisors(Required)NamePhone NumberBest Time To CallOccupation Add RemoveIF ADMITTED INTO THE PROGRAM I WILL PROVIDE A GED / HIGH SCHOOL TRANSCRIPT / ATTESTATION BEFORE THE FIRST DAY OF CLASSProspective Student's Signature(Required) ENROLLMENT AGREEMENT 3622 Shannon Road Suite 103 Durham, NC 27707 (919) 908-9939 STUDENT INFORMATION STUDENT NAME(Required) First Last ADDRESS(Required) City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code TELEPHONE #'S HCell(Required)Email(Required) SOCIAL SECURITY #(Required)EMERGENCY CONTACTEMERGENCY CONTACT #'SPROGRAM INFORMATIONDATE OF ADMISSION:(Required) MM slash DD slash YYYY PROGRAM / COURSE NAME: Nurse Aide I PROGRAM START DATE(Required) MM slash DD slash YYYY ANTICIPATED END DATE(Required) MM slash DD slash YYYY DAY CLASS / EVEING CLASS MEETS:TIME OF DAY / EVENING CLASS BEGINS:TIME OF DAY / EVENING CLASS ENDS:NUMBER OF WEEKS(Required)TOTAL HOURS(Required)CRIMINAL BACKGROUND – Separate Fee Not included in tuition/ separate fee. Students would be invoiced, once criminal background has been run. CANCELLATION REFUND POLICY for Full Payment Students A student refund shall not be made except under the following circumstances 1. A student is eligible for a partial refund, if the class in which the student is officially registered is cancelled due to insufficient enrolment. 2. A student will receive a partial refund of $400 dollars up to the 25% point of the program, if the student decides to withdraw from the program. Cancellation Refund Policy for Payment Plan Students A student refund shall not be made for students under the payment plan. 1. If a student joins the payment plan and pays the first instalment of $355 dollars and decides to withdraw no matter the circumstances the student will NOT receive a refund. 2. If a student who is on the payment plan decides to withdraw from the program before or after the first day of the program the student will receive NO refund. WITHDRAWAL PROCEDURE: 1. A student choosing to withdraw from the school after the commencement of classes is to provide a written notice to the Director of the school. the notice must include the expected last date of attendance and be signed and dated by the student. NOTICE TO PROSPECTIVE STUDENT: 1. Do not sign this agreement before you have read it or it contains any blank spaces. 2. This agreement is a legally binding instrument. Both sides of the contract is binding only when the agreement is accepted, signed and dated by the authorized official of the school or the admission officer at the school's principal place of business. Read both sides before signing 3. You are entitled to an exact copy of this agreement and any disclosure pages you sign. 4. This agreement and the school catalog constitute the entire agreement between the student and the school. 5. The school reserve the right to reschedule the program start date with the number of students schedule is too small. 6. The school reserves the right to terminate a students' training for unsatisfactory progress, nonpayment of tuition of failure to abide established standards of conduct 7. The school does not provide accommodations for RELIGIOUS Practices STUDENT ACKNOWLEDGMENTS: I hereby acknowledge receipt of the school’s enrollment agreement form dated Date(Required) MM slash DD slash YYYY which contains information describing programs offered, and equipment/supplies provided.student initials(Required)2. I have carefully read the enrollment agreement form in its entiretystudent initials(Required)3. I understand that the school may terminate my enrollment if I fail to comply with attendance, academic, and financial requirement or if I fail to abide by established standards of conduct. While enrolled in the school, I understand that I must maintain satisfactory academic progress and that my financial obligation to the school must be paid in full before a certificate may be awarded.student initials(Required)APPLICANT’S STATEMENT I certify that answers given herein are true and complete. I understand providing false or incomplete answers may result in disciplinary action, including denial of admission or dismissal after admission. I agree to abide by the rules, policies, and regulations of Wisdom Health Academy.Name(Required) First Last Signature(Required)Date(Required) MM slash DD slash YYYY Interview FormHow did you find about Wisdom Health Academy program?What are your plans after Graduation?Are you interested in doing a paid internship if selected? (We work with a home care agency that will outsource In-Home Aides and / or CNA to client’s homes.) YES NO Do you have your transcript?(Required) YES NO Do you have a current TB test?(Required) YES NO Do you have ID/SSN?(Required) YES NO Wisdom Health Academy 3622 Shannon Road Suite 103 Durham, NC 27707Print Name(Required) First Last Consent(Required) I agreeMe, a student of Wisdom Health Academy give permission to share or allow a copy of my criminal background report to be given to any facility who requires the information in an effort to participate in clinical laboratory instruction as a requirement of Wisdom Health Academy. I understand that the criminal background is not included in my tuition and I will be invoiced once the criminal background report has been run. I understand that my failure in paying the invoice for my criminal background will result in me not receiving my certificate of completion. I also understand my continuation in the program will be based upon completing my clinical rotation.Student Signature(Required)Date(Required) MM slash DD slash YYYY Wisdom Health Academy StudentName(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email(Required) Home Phone:Cell(Required)Emergency ContactName First Last Phone Wisdom Health Academy Student Hepatitis – B Vaccination Declination FormConsent(Required) I agreeI understand that duet to my possible occupational exposure to blood o other potentially infectious materials during my clinical/ class training. I may be at risk of contracting Hepatitis B virus (HBV). It has been recommended that I receive the Hepatitis B Vaccination series at my own cost, from a physician or medical facility of my choice. However, I decline to have the Hepatitis B vaccination at this time. I acknowledge that the choice not to be vaccinated in my choice and that the choice not to be vaccinated in my choice and that exercised my own free will in choosing not to receive the vaccine, and therefore assuming the risk that I may contact the disease. As a condition of the right to participate in the clinical training of my program, I personally assume all risks incident to the waive and release any claim I might have or claim that I have against Wisdom Health Academy as a result of contacting the disease (s).Consent(Required) I agreeI understand that this waiver and release shall apply to any liability, loss, damage, action, cause of action, or cost of any kind, nature or sort that my or could arise in connection with my exposure to the disease.Consent(Required) I agreeI do specifically agree to indemnify and hold Wisdom Health Academy harmless against all loss which might incur should I contract this disease.Signature(Required)Date(Required) MM slash DD slash YYYY Consent(Required) I agreeI was given the opportunity to ask questions and to understand this document and the risk involved. I also attest that I’m over 18 years old and can legally sign this form. Wisdom Health Academy Waiver and Assumption of RiskConsent(Required) I agreeI here by fully waive and release Wisdom Health Academy from any and all claims for personal injury, property damage, or death that may result from participation in any physical activities required as a student in training of Wisdom Health Academy. I hereby voluntarily, at my own risk, sign this Waiver and Assumption of Risk in sole consideration of being permitted to use the company’s facilities, property, clinical settings or outside agencies which have been fully explained to me. I further agree to indemnify and hold harmless Wisdom Health Academy, its employees, instructors, agents from and against any and all liability incurred as a result of or in any manner related to my participation in the activities. I certify I am of legal age to execute this Waiver and Assumption of Risk, have read and understood and acknowledge my consent to the terms of this Waiver and Assumption of Risk by signing this Waiver.Online Theory(Required) I agreeFailure to complete online theory by the stated deadline date and time will result in forfeiture of your seat in the current class, no refund will be issued unless otherwise stated in writing from the administrator. Students will be eligible to re-enroll in the next available course session. By submitting payment and enrolling, you acknowledge and accept these terms. Student Name(Required) First Last Signature(Required)Date(Required) MM slash DD slash YYYY Documents students need to uploadTB Test Results(Required)Max. file size: 250 MB. Official high school or college transcript(Required)Max. file size: 250 MB. copies of drivers license(Required)Max. file size: 250 MB. social security card(Required)Max. file size: 250 MB. covid-19 vaccination card(Required)Max. file size: 250 MB.
