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 |
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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
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