Nurse Aide Class Registration
This form MUST be completed and returned to:
Iowa Western Community College, Continuing Education, Looft Hall, 2700 College Rd, Council Bluffs, IA 51503
FAX: 712.325.3721 or EMAIL: swiese@iwcc.edu
COURSE
Course #:
Course Date:
STUDENT INFORMATION
Name:
Date of Birth:
SSN:
Home Address:
Cit y:
State:
Phone (h):
(w ):
Email:
Citizen: US Other (Specify) Male Female
TUBERCULOSIS (TB) SCREENING
Physician documentation of a negative 2-St ep TST (
2 separate TB tests
) MUST accompany registration form.
Date Read
1
st
TST Date given Date Read
Results (Record actual mm of induration, transverse diameter; if no induration, write “0”
2
nd
TST Date given _
_____________ _____________
_____________
_____________ ____________
Results (Record actual mm of induration, transverse diameter; if no induration, write “0” ______________
CRIMINAL BACKGROUND CHECK
Fill out one line for each name you have had (maiden, married, etc.)
1.
Last Name Current
(Mandatory)
First Name
(Mandatory)
Middle Name
(Mandatory)
2.
Last Name Previous
(Mandatory)
First Name
(Mandatory)
Middle Name
(Mandatory)
Do you have a record of founded child or dependent adult abuse or have you ever been convicted of a crime ot her than
a simple misdemeanor offense relat ing t o motor vehicles and law s of t he road under chapter 321 or equivalent provisions,
in this state or any ot her st ate? No Y es
I give Iowa Western Community College permission to complete an IOWA CRIMINAL HISTORY check. The information I have furnished
is accurate and complete.
Signature:
Date:
PAYMENT
If you work in a nursing home or have been promised a job at a nursing home, they must pay for your class we cannot accept payment
from you. If you gain employment at an Iowa nursing home within 12 months, they must reimburse you for the class/test.
Payment method: Money Order Cashier’s Check Cash Credit/Debit Card
Credit/Debit Card #:
Exp. Date:
3-Digit Code :
Name on Card:
Billing Address:
Paye e Email:
11/9/18