Agency Enrollments for ONLINE Course Please enable JavaScript in your browser to complete this form. - Step 1 of 6Online CNA Test Prep Course Registration Dear Applicant: Thank you for your interest in 4YourCNA's Online CNA Test Prep Course. This course is designed to review all you will need to know to pass the certification exam to become a Certified Nursing Assistant and will assist you in developing the skills you need to become a respected member of the healthcare team. The cost of the ONLINE ONLY interactive course is $149. This fee is only for the online course content and does not include any additional books, learning materials or instructor critique. This course is designed to help the student self-prepare for the state exam. However, our classroom is live-streamed into the first lesson, allowing online students to participate in the classroom instruction in a virtual environment. Replays and worksheets are also available in this lesson. There are no additional fees for this opportunity. The CNA Skills Study Guide by Patricia Laramee, RN and Hartman's Nursing Assistant Guide, The Basics by Jetta Fuzy, RN are recommended, but not required. These resources, as well as others, can be added on during the enrollment process. Course fee does NOT cover the cost of background screening fee of $80 (if applicable) or state testing fee of $155 (payable to Prometric, the testing agency). Test registration instructions are provided in the course. There are no refunds after registration is complete. Please fill out the following application entirely. Thank you for your interest. Best Wishes, Patricia Laramee, RN Instructor Home of the #1 CNA Test Prep Video Series on YouTube! Additional Information can be found at www.4YourCNA.com NextOnline CNA Test Prep Course $149 Online only - Self-study IMPORTANT: This course can be accessed at courses.4yourcna.com. You will set up your username and password as part of this registration process. Please make a note of it - you will need to it access the course materials. courses.4yourcna.com PreviousNextOnline Course Registration Fee The total registration fee for this course is $149 and does not include books, practice supplies or test registration fees. No other fees are required, although supplemental study products are strongly encouraged and available for additional purchase, if desired (see below). Please indicate the Agency that should be invoiced for this enrollment: Agency that agrees to pay $149 for course enrollment: *Scholarship (Dr. Brown)Vocational RehabMid-FloridaEmployerOtherPayor NameIMPORTANT: All enrollments paid for by a third party must be pre-authorized by the payment provider. Authorization must be verified by 4YourCNA before the enrollment is officially accepted. Enrollment is not granted until payment source is verified. PLEASE NOTE: the following information is required if an AGENCY or FACILITY will be paying for the course. All sections need to be completed for enrollment. The following information is regarding the PAYOR source, not the student's information. How should agency be invoiced? *--- Select Choice ---EmailPostal MailCounselor/Authorizing Contact Name *FirstLastEmail *Phone *Include extension if necessaryAddress to send Invoice to:Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeAdditional Resources (optional):CNA Skills Study Guide $45.00Hartman's Nursing Assistant Textbook $42.00Student flashcards $19.99Student Practice Kit $49.99CNA Principles Card Game $24.99The authorizing agency/payor source will be invoiced for the class registration fee of $149 PLUS each option selected under "Additional Resources". An additional shipping charge of $14.99 will be applied if any additional resources are purchased and shipped to the student. All fees are non-refundable. An invoice will be submitted after registration and must be paid in full within 15 days. Check this box if you are tax exempt:Payment is being made from a tax-exempt organizationPreviousNext4YourCNA TEST PREP REGISTRATION FORM Complete this form to register After completing all sections of this form, the agency you indicated will be contacted to verify authorization. Your registration is not complete and access will not be initiated until verification has been made by 4YourCNA. Please complete the following information for enrollment - this section is for STUDENT information. STUDENT Username for site *You may use your email address as a username or create your own.Create Password *PasswordConfirm PasswordCreate a password of at least 8 characters with numbers, letters and symbols.Name *FirstLastAddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeRequired if additional supplies were ordered and will be shipped to the student.Phone *Email *Important: Please readThis class is taught in English only. To perform competently as a healthcare professional, you must be able to communicate effectively in English, both verbally and in writing. To work in healthcare, it is recommended that you have the ability to walk or stand for up to eight hours a day, reach, bend, push, pull and (for CNA’s) lift at least 50 pounds. You also need to have adequate eyesight and hearing. To obtain state certification for C.N.A. in Florida, each applicant must pass a criminal background check as well as pass the state exam. If you feel your criminal history may prevent you from obtaining your certification, please discuss this with the CNA Registry prior to registration for the class. Once registration is complete, no refunds will be given for any reason. PLEASE READ AND ANSWER THE FOLLOWING Are you able to perform the above minimum physical requirements? *YesNoHave you taken the CNA licensing exam in Florida in the last 2 years? *YesNoCan you read and write in English? *YesNoHave you taken the exam a total of 3 times in the last 2 years?YesNoSTOP! Do not register. This course does not meet the testing criteria for your 4th attempt. No refunds are given after enrollment. This class is only given in English. The clinical exam must be completed in English, although the written exam is also available in Spanish. It is strongly recommended that you are able to read and write in English in order to gain the required knowledge this class provides. You may enroll, but no accommodations will be made for language barriers. Do you have a criminal history that you feel may prevent you from obtaining your certification? *YesNoIF YES, STOP. PLEASE CALL THE CNA REGISTRY AT 1-850-245-4567 PRIOR TO REGISTRATION.How did you hear about us? *Google searchYouTubeEmployerReferral (relative/friend)Social MediaOtherNextTERMS AND CONDITIONS Please write your initials in the space provided before each section. By submitting this application, you certify and attest that you have read and agree to the following: PLATFORM: (input your initials in the box to agree) *The online CNA Test Prep Course is a self-paced, independent study platform for students to self-prepare for the CNA State Exam in Florida, given by Prometric. There is no attendance requirement, no verification of compentency, no monitoring of course progression or grades, and no certificate of completion. This material is informational in nature, and provides no assurance of test-readiness. Students must be able to complete the content without supervision, prompting or outside motivation. Students will have one year of access after enrollment. There are no opportunities for extension and if the student does not complete the content in that time frame, the student would be required to re-enroll to gain further access. Students are encouraged to evaluate their own learning styles prior to enrollment. There are no refunds offered - to either the student or the agency payor - for failure to complete the course content. FEES: (input your initials in the box to agree) *Fees include access to the learning platform and all lessons, activities, quizzes, livestreams, worksheets and videos within. It does NOT include recommended resources, such as the CNA Skills Study Guide, CNA Textbook or student practice kit. This online course includes classroom livestream/replays during class sessions, available in the first lesson. Students are able to ask questions live and receive immediate instructor explanations and feedback. Test registration instructions are presented in Class 4 of the livestream and in a dedicated section within the online course. Fees for State examinations and Background Checks required for testing are not included in the cost of the class. LIABILITY WAIVER: (input your initials in the box to agree) *You are entering into an agreement with 4YourCNA of your own free will. These courses are designed to review the basic skills you will need to pass the state examination. This is done strictly in an online interactive format. There is no provision for practicing your skills on "live patients". You are encouraged to practice the skills you are learning prior to taking your state exam. 4YourCNA does not assume any liability for any harm done, inadvertently or intentionally, to yourself or others for any portion of any skill performance. No assumption of liability may be made for any injury to yourself or any other person that may occur before, during or after practice. By submitting this application, you absolve 4YourCNA from any and all liability for any injury to yourself or any other person as a result of practicing any skills you have learned from 4YourCNA resources. Please sign to complete the online course enrollment: ONCE PAYMENT HAS BEEN MADE, NO REFUNDS WILL BE GIVEN FOR ANY REASON. Date MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name *Full NameSignature Clear Signature NextPayment Authorization Dear Student: Thank you for completing the registration paperwork. We will contact the authorizing agency to verify payment source and invoice them. You will receive a welcome email from 4YourCNA once the agency agrees to sponsor your enrollment. Please remember, you will need the username and password you created during this enrollment process to access the lessons. Write it down and put it in a safe place. Access the lessons on courses.4YourCNA.com! Get started on the unlocked (free) lessons or watch the classroom livestream and replays while you are waiting! Submit
