VIP Nursing School
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VIP Nursing School,  Inc. HHA Application  4102501   Revised 05/12

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VIP NURSING SCHOOL, Inc. 16388 East 14th Street, San Leandro, California 94578  

Office: (510) 481-0240; (510) 481-0360:  Fax: (510) 481-0242  

Web Site: www.vipnursing.net: Email: info@vipnursing.net

      
A.  HOME HEALTH AIDE STUDENT REGISTRATION & ENROLLMENT AGREEMENT

Student Name:________________________________________________________________________________________________  Sex:  Male{  } Female{  }         
                             Last                                                               First                                                        Middle Initial
Address:____________________________________  _______  _______________      _________     ______________     
                Street                                                     Apt.#            City                    State             ZIP Code
Home Phone:____________________________ Work Phone:___________________ Cell phone: __________________           

Social Security No:________-______-__________Occupation: __________________ Employer:____________________
Person to Contact in case of Emergency:______________________Relationship:___________Phone:_______________
Are you at least 16 years of age? Yes{  } No{  }  Date of Birth: _________________ CA Drivers Lic.__________________
Place of Birth: __________________Color of Eyes: ________ Color of Hair: ________Weight: ________ Height: _______
Marital Status: Married{  }  Single{  }  Separated{  }  Divorce{  }  Email:________________________________________

Bring proof United States High School Diploma, or GED equivalency completion, or proof of passing score of Ability to 
     Benefit Test  (ATB)  Yes{  }  No{  }   
Do you have a current CNA license?  Yes{  } No{  }                                    Are you 16 years old or older?  Yes{  }  No{  }   

*There is NO English as a Second Language instruction.

Have you ever been convicted by any court of law of a crime, other than a minor traffic violation?   Yes{  }    No{  }  
If you answer Yes to this  question, You must supply the following information to Department of Health Services in Sacramento:

A.    Date and nature of the incident(s)                           D.   Letters from your probation Officer (if applicable)   

B.    Disposition of the case (Provide Court papers)      E.    Letters of recommendation (if applicable)

C.  Current status



 WORK EXPERIENCE 
  Employer                                    City/State/County         Job Title                                               Dates           Reason for Leaving

______________________  _______________  _________________________   ________  ______________________

 

______________________  _______________  _________________________   ________  ______________________

B.  COMPLAINT NOTICE

 “Any questions or problems you may have regarding the catalog that have not been satisfactorily answered by the VIP School, you may direct to:

BUREAU FOR PRIVATE POSTSECONDARY EDUCATION

2535 CAPITOL OAKS DRIVE, Suite 400, Sacramento, California 95833

Mailing Address: P.O. Box 980818, West Sacramento, CA 95798-0818

Toll Free Telephone number (888) 370-7589, or byFAX: (916) 263-1897

Web site: www.bppe.ca.gov

“A student or any member of the public may file a complaint about this institution with the Bureau for Private Postsecondary Education by calling (888) 370-7589 toll-free or by completing a complaint form, which can be obtained on the Bureau’s internet web site www.bppe.ca.gov

___________________________________________________Signature. Initial & Date         

Records must be kept for 5 (five) years. VIP School Revised  05/12 page 1 of  6                                  






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