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Certified Nursing AssistantSchedule of upcoming classesNovember 7, 2016 –November 28, 2016 –January 9, 2017 –January 30, 2017 –February 20, 2017 –March 20, 2017 –April 10, 2017 –May 1, 2017 –May 22, 2017 –June 12, 2017 –November 23, 2016December 14, 2016January 26, 2017February 15, 2017March 8, 2017April 5, 2017April 26, 2017May 17, 2017June 7, 2017June 28, 2017**All classes are subject to a minimum class size and may be canceled if therearen’t enough students registered to support the class. We will move you to thenext class should this happen.Thank you for your interest in the CNA Program. Our day class is an 90 hours program that meets overthe course of three weeks from 8:00am – 3:00pm. In order to enroll in the class you will need tocomplete and return the application along with the Notarized Healthcare Criminal History BackgroundAffidavit, results of your TB skin test, copy of your valid ID, and your tuition for 275. Please bring yourcompleted application to the Pearl River Community College Lowery A. Woodall Advanced TechnologyCenter located behind the Forrest County Multi-Purpose Center in the Hattiesburg Industrial Park. Ouraddress is:PRCC- Woodall CenterAttention: Lee Bell

906 Sullivan DriveHattiesburg, MS 39401Classes are held on the Forrest County Campus of Pearl River Community College in Building 2, Room101. (See attached map)Expenses:Tuition is 275 which includes your workbook and state testing fee for the NACES state examNavy Blue uniform -Approximately 35 - 40 at uniform stores in townThe one step TB skin test which is approximately 30 at the health department or you may see yourpersonal physician.Financial AidRegular tuition assistance, through FAFSA such as Pell Grants and student loans is not available for thisprogram. You can contact your local Pearl River Valley Opportunity (PRVO) to see if you qualify for agrant or scholarship. You must contact PRVO in addition to PRCC if you would like to apply. You may beeligible for SNAP training assistance if you are SNAP eligible. At this time, the CNA program isn’t eligiblefor assistance through the WIN Job Center.We can provide a Letter of Acceptance once you have turned in a completed application. We will notplace you on a class roster until your tuition is paid or we have received notification from one of theagencies that your tuition will be paid.**IMPORTANT**If you are applying for assistance through SNAP, you will need to work with your case manager at DHS aswell as Sonya Hunt with Pearl River Community College. She can be reached at (601) 336-0069. Youwill work with her for the entire enrollment process and not through the Woodall Center.

Get Id madehereClass meets inroom 101 ofBuilding 2

Return Application to:Audrey SmithPhone: 601-554-4646Fax: 601-554-4640Email: Asmith@prcc.eduwww.woodallcenter.comApplication forCNAPersonal InformationLast Name:Birth Date:Emergency Contact:Permanent Address:Mailing Address:CityPersonal Email Address:First Name:SSN:Middle Initial:Contact Phone #:Apt #Apt #State:Zip Code:Phone Number:Demographic InformationSex: MaleFemaleWould you describe yourself as Hispanic or Latino? YesNoRace: AsianBlack/African AmericanWhiteHawaiian/Pacific IslanderAmericanIndian/Alaskan NativePlease indicate which of the following best describes your level of education:Less than high schoolHigh School diploma/HSEAssociate DegreeSome CollegeGraduate/Professional degreeSPlease indicate your current employment status: EmployedUnemployedoRetiredIf employed, which of the following best describes your employment situation: mFull TimePart TimeSeasonaleAre you a US Citizen YesNoAre you a Veteran? YesNoSWork ExperiencesomeDisclaimerNo refund after first day of class. Applicant must be out of high school and 18 before the first day of class. Enrollment isreserved upon receipt of the completed application, full payment of 275 tuition, copy of MS Sate issued ID, proof of negativeTB test result and notarized Healthcare Criminal History Background AffidavitPearl River Community College offers equal education and employment opportunities. The College does not discriminate on the ba sis of race, religion, color, sex, age,national origin, veteran status, or disability. For inquiries regarding the non-discrimination policies or to request accommodations, special assistance, or alternateformat publication please contact Tonia Moody, Director of Admissions and Records, ADA/Civil Rights, and Title IX Coordinator , at P.O. Box 5537, Poplarville, MS 39470or 601-403-1060.Signature:Date:

Criminal History Record CheckInformation as it Pertains toCNA Students at Pearl River Community CollegeFor the purpose of fingerprinting and criminal background history checks, the term “affidavit” means theuse ofMississippi State Department of Health (MSDH) Form # 210, or a copy thereof, which shall be placed inthe individual student’s file.A person signing an Affidavit must affirm that they have NEVER been convicted of nor plead “no locontender”(no contest) to any felony, including, but not limited to the ion or sale of drugsMurderManslaughterArmed robberyRapeSexual batterySex offense listed in Section 45-33-23, Mississippi Code of 1972Child abuseArsonGrand larcenyBurglaryGratification of lustAggravated assaultFelonious abuse and/or batter of vulnerable adultIf a person signs the affidavit required, and it is later determined that the person actually had beenconvicted of or pleaded guilty or no lo contendere (no contest) to any of the offenses listed herein, andthe conviction or plea has not been reversed on appeal or a pardon has not been granted for theconviction or plea, the person is guilty of perjury as set out in Section 43-11-13, Mississippi Code of1972. The licensed facility and Pearl River Community College shall immediately institute terminationproceedings against the student pursuant to the facility’s policies and procedures.Pearl River Community College may, at any time, request a background check at the student’s expense.If the student is unable to pass the background check; they will be unable to participate in the clinicaltraining required for completion of the program, therefore, student will unable to complete the program.Definitions

Possession or Sale of Drugs: Found guilty of having, holding, or selling of illegal substancesMurder: The unlawful killing of a human being by another with malice aforethought, either expressed orimpliedManslaughter: The unlawful killing of another without malice, either expressed or implied; which maybe either voluntarily, upon a sudden heat, or involuntarily but in commission of some unlawful actRape: Forced intercourse without consentSexual Battery: Hitting or touching a person on his/her clothes or anything he/she is holding in way thatindicates sex or sex actsArson: The malicious burning of one’s own property or another’s with intent to defraud or prejudice aninsurer thereofBurglary: The breaking and entering the house or property of another with intent to commit a felonytherein, whether the felony be actually committed or notFelony: a crime more serious than a misdemeanorFelonious: of the nature of or referring to a felonyFelon: Someone guilty of a felony/has a felony convictionFelony Possession or sale of drugs: Found with having; holding, or making sale of some illegal drug in anamount as to result in a felonyArmed Robbery: To take property from a person with force and use of some type of weapon.Grand Larceny: Theft of item(s) valued over 250.00Burglary: The act of breaking into a place for the purpose of stealingAggravated assault: An unlawful threat to use force against another which causes them to be fearful.Felonious abuse or Battery of a Vulnerable Adult: To attack, use force or blows against a person who iselderly or above age 65 or against a person over age 18 with mental or physical disabilities and infirmitieswho is unable to fend off an attacker. Further includes any adult residing in a long term care facilityCarnal knowledge: sexual knowledge/information about sexUnnatural Intercourse: sex acts not accepted as normalAdultery: Voluntary sexual acts between unmarried personsFornication: Sexual acts between unmarried personsKidnapping: To take away and hold by forceIntent to Ravish: Attempt to rapeEnticing a child: Offering something to a person under 18 years of age in order to cause them to ceaseresistance.Prostitution: The act of offering sex or sex acts for moneyGratification 0f Lust: Touching a person, usually a child, under age 18 for lustful or sexual purposeDissemination of sexually oriented material: Distribution of sexually oriented/ graphic material tomaterial to persons under 18 years of ageExploitation of children: To use a person under 18 years of age for one’s own selfish endsChild Abuse: Conduct toward an emancipated child under 18 years of ages by the parents, guardian, orother person, who cares for, has custody of or authority over the child. There are four degrees of abuse:First Degree-occurs when the defendant knowingly or intentionally causes serious physical or mentalabuse. Second Degree-Occurs when the defendant willfully abandons the child, fails to provide food,clothing or shelter necessary for the child’s welfare, or commits a reckless act which results in serious

physical or mental harm. Third Degree-occurs when the defendant knowingly or intentionally causessome physical harm to the child. Fourth Degree- occurs when the defendant abandons the child, orwillfully fails to provide food, clothing or shelter necessary for the child’s welfare, or commits a recklessact, which results in some physical harm to the child.I have read the above information and it has been explained to me.Printed Name:Signature: Date:

State of MississippiBefore me, a Notary Public in and for the County of andState aforesaid, personally appeared the undersigned who,After being by me duly sworn did state upon his/her oath as follows:a.That the affiant is currently enrolled at Pearl River Community College in a healthcareprofessional/Workforce program or is an applicant for such programb.That the affiant has not been convicted of or pleaded guilty or no lo contendere to a felonyof possession or sale of drugs, murder, manslaughter, armed robbery, rape, sexual battery,sex offense listed in Section 46-33-23(f), Mississippi Code of 1972, child abuse, arson grandlarceny, burglary, gratification of lust; aggravated assault; or felonious abuse and/or batteryof a vulnerable adult; that has not been reversed on appeal or for which pardon has notbeen granted.c.That the affiant understands that a fingerprint/background check may be required at anytime by Pearl River Community College in accordance with section 37-29-232 of theMississippi Code and any information gained through such query that indicates a convictionof any of the offences listed above will result in termination of enrollment.d.The affiant also understand that any future background checks conducted by licensureboards or employers which yields information pertaining to conviction of those crimes listedabove as well as others may cause said licensure board or employer to refuse licensure oremployment.Name of Affiant (Printed)Signature of AffiantSWORN TO AND SUBSCRIBED BEFORE ME, this day of , 20Signature of Notary PublicMy Commission Expires

Certified Nursing Assistant Schedule of upcoming classes November 7, 2016 - November 23, 2016 . Thank you for your interest in the CNA Program. Our day class is an 90 hours program that meets over the course of three weeks from 8:00am - 3:00pm. . Asmith@prcc.edu www.woodallcenter.com Application for CNA S o m e S s o m e .