QMA Program Application Personal InformationName* First Middle Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Cell Phone*Alternative PhoneDate of Birth* Date Format: MM slash DD slash YYYY Have you previously been enrolled in this course at SWIHSA? Yes No Have you previously been a QMA? Yes No You must meet the following requirements to participate in this program:Are you at least 18 years of age or older?* Yes No Do you have a high school diploma or GED?* Yes No Have you worked as a CNA for a minimum of 1000 hours within the last 24 months?* Yes No Do you currently work in a nursing facility? Yes No If YES, please provide the following:Facility Contact NamePhone NumberHow will you be paying for the class?Cost: $1,400.00 Private Pay Applying for a Sponsorship Sponsor FacilityContact NamePhoneHow did you hear about the SWIHSA program? Advertisement Employer Employment Agency Friend / Relative Facebook Other Applicant's StatementThe Indiana Department of State says if you have anything on your criminal history that is listed below you may not be able to attend the CNA Program. Please indicate if you have been convicted of the following:A sex crime* Yes No Exploitation of an endangered adult* Yes No Failure to report battery, neglect, or exploitation of an endangered adult* Yes No Theft within the previous five (5) years* Yes No Murder* Yes No Voluntary manslaughter* Yes No Involuntary manslaughter within the previous five (5) years* Yes No Felony battery within the previous five (5) years* Yes No A felony offense relating to controlled substances within the previous five (5) years* Yes No Abused, neglected, or mistreated a patient or misappropriated a patient’s property; and had a finding entered into the state nurse aide registry* Yes No Are you a person who knowingly or intentionally applies for a job as a nurse aide or other unlicensed employee at:*(1) a health care facility; or (2) an entity in the business of contracting to provide nurse aides or other unlicensed employees for a health care facility; after a conviction of one (1) or more of the offenses listed above? Yes No The Indiana State Department of Health requires that you must be able to pass a drug screen. Any samples provided that do not pass Deaconess Comp Centers criteria could automatically disqualify you from this program.*Please inicate that you understand the above statement and are able to pass a drug screen provided by deaconess comp center. Yes No By submitting this application, I acknowledge that I have answered the above questions to the best of my knowledge.NameThis field is for validation purposes and should be left unchanged.