*full payment must be made to complete your online registration*

Please note that upon completion of this registration packet, payment must be made in order to submit. If you are unable to make a payment at this time OR have questions, please call our office at 515-252-0000, between 9:30 AM and 5:30 PM.

Tuition for the program is $700.00 which includes books, lab supplies and clinical time. Documentation of a 2-Step TB skin test (within 12 months) is required at least one week before class begins. Students who fail to provide documentation will not be allowed to attend clinical sessions. Full tuition is due within 7 days prior to the start of class. Seats are limited and reserved by full payment. Students must fill out the criminal background request form (included in this packet) for Signature Healthcare. Completion of criminal background checks may take as long as three weeks to process. Students will not be allowed to start class until full background checks have been approved and all other required documents have been turned in.

NOTE: Tuition paid by the applicant will be refunded up to 72 hours prior to the start of the course with an exception of a $75.00 administration fee. No refunds will be made after 72 hours prior to the start of the course. Refunds requested prior to 72 hours to the start of the course will be dispersed no more than 21 business days after verbal request.

If you are unable to finish the course or do not pass the course, you will be charged an additional fee to retake the course. If you miss more than 7.5 hours of this 75 hour course, you will not pass. If you have less than 75%, you are not allowed to attend clinical days, therefore will not pass the course.

Note: Any nurse aide who is employed by or who has received an offer of employment by a facility on the date on which the aide begins a nurse aide training and competency evaluation program may not be charged for any portion of the program. This includes any textbook fees, other required evaluations and/or course materials.

Student Agrees to and Understands:

1.) Follow program rules and standards including dress and conduct.

2.) Notify Program Coordinator immediately if I am dismissed from the practicum-clinical site.

3.) Preserve the confidentiality of patients of the practicum-clinical site

and comply with all confidentiality policies and procedures of the practicum-clinical site and Signature Healthcare.

4.) I will be automatically dropped from the course after I miss 7.5 hours or 10% of the course, regardless of the cause.

5.) I must be fluent in English (able to speak, understand, read and write).

6.) I must complete ALL 75 hours to successfully pass the course. If I miss any clinical or classroom time I will make up the missed hours. I understand that clinical make up dates must be completed within 30 days of the original course date, as scheduled and approved by the Program Director. I further understand that Signature Healthcare does not guarantee clinical make up hours.

7.) I must call the phone number provided to me, prior to missing lecture/lab/clinical.

8.) I will be sent home from clinical if I am not dressed appropriately (as stated in the course syllabus) or fail to bring my skills checklist.

9.) 10 minutes or more qualifies as a tardy. Three (3) documented ‘tardies’ equals 1 missed day (7.5 hours).

10.) I must act in a professional manner at all times. The following are unacceptable during lecture/lab/clinical times: foul language, cell phone usage, texting, audible alarm pagers, and/or disruptive behavior. I will respect my instructors, fellow classmates, clinical nursing team, and guest speakers. I understand failure to do so are grounds for dismissal of this course.

11.) During clinical hours, all facial piercings must be removed and/or covered. One pair of post earrings only, hair off shoulders and no artificial nails. No nail polish – or neutral polish with no chips.

12.) I understand that if I become ill during this course I will not attend lecture/lab/clinical. Signature Healthcare defines illness as having 1 or more of the following symptoms: fever, sore throat, muscle aches, vomiting, diarrhea and/or a productive cough.

Signature Healthcare Agrees to:

1.) Communicate regularly with practicum-clinical site for successful performance.

2.) In cooperation and consultation with practicum-clinical sites, share program competencies – understandings, skills, and abilities) to be learned by the student.

3.) Grant appropriate grades and scores for successful performance.

4.) Provide insurance coverage sufficient to defend, indemnify and hold practicum-clinical site harmless from (a) any and all claims by or injuries to others and (b) any and all claims by or injuries to students, arising out of or related to student’s work conduct or any activities necessarily associated with this training agreement, except vehicular travel in non-Signature Healthcare vehicles.

5.) Provide insurance coverage sufficient to defend, indemnify and hold Signature Healthcare and student harmless from injuries to or claims by student or any other party arising out of or related to students work conduct or any activities necessarily associated with this training agreement, except vehicular travel in non-Signature Healthcare vehicles.

6.) Treat student without regard to race, color, creed, sex, origin, religion, age, disability or veteran status.

To: Iowa Division of Criminal Investigation

Support Operations Bureau, 1st Floor

215 E. 7th Street

Des Moines, Iowa 50139

Phone: (515) 725-6066

From: Signature Healthcare

14225 University Ave. Ste. 130

Waukee, IA 50263

Phone: (515) 252-0000

Waiver Information: Without a signed waiver from the subject of the request, a complete criminal history record may not be releasable, per Code of Iowa, Chapter 692.2. For complete criminal history record information, as allowed by law, always obtain a waiver signature from the subject of the request.

Waiver Release: I hereby give permission for the above requesting official to conduct an Iowa criminal history record check with the Division of Criminal Investigation (DCI). Any criminal history data concerning me that is maintained by the DCI may be released as allowed by law.

I understand that participation in a clinical experience is part of this training program. Clinical experiences include working in affiliating health care facilities. I further understand that these health care facilities have the right to establish requirements for participation in clinical experiences. These requirements may include submission of my criminal records check obtained by Signature Healthcare. Results of my criminal record checks may be released to clinical health care facilities so I can be screened for acceptance into facilities for clinical experience. Further, I give the Division of Criminal Investigation (DCI) permission to release information to Signature Healthcare pertaining to my criminal record check.

I understand that due to my occupational exposure to blood or other potentially infectious materials during my clinical practicum that I may be at risk of acquiring Hepatitis B virus (HBV) infection. I can download a copy of CDC’s Hepatitis B: Get the Facts handout on Signature Healthcare's website. I have been informed and understand that I should be vaccinated at my own expense. If I currently work as an employee in a health facility and have a potential exposure to blood, my employer is to cover the cost of the Hepatitis B vaccination. I further understand that by declining this vaccine I am at risk of acquiring Hepatitis B, a serious disease. I hereby release Signature Healthcare, LLC and my clinical practicum site of any responsibility if I should contract Hepatitis B while I am a student.

I further am not aware of any physical limitations that will interfere with my participation in the class or in the clinical setting to the full expectation of my instructors and myself. If I do experience a health condition that could possibly limit my ability to participate in class or clinical, it is my responsibility to notify Signature Healthcare. I understand I will be required to provided a dated physician statement if a medical emergency arises after the start of class. I further understand that if my physician does place restrictions on my participation in this class (sitting, lifting, standing, bending, etc.) I will be dismissed from class without financial refund. Signature Healthcare will make every effort to offer a future class date when a seat becomes available. This will be organized through the Admissions Coordinator and transfer fees will be applied.

PAYMENT OPTIONS:

1.) Pay with a Credit Card / Debit below

2.) Pay in person at our office

**Submitting the registration form without making full payment does not reserve a seat in the class**