Health Career Solutions, Inc. 
Application of Enrollment 
Name: Last: 	First: 	-r-r- 	_ 
Street Address 		City 	Zip 
Phone: 	D.O.B. 	5511 XXX-XX 	_ 
Email 	_ 
Have you ever been convicted of any defense? __ Yes __ NO 
Felony 	Misdemeanor 	(Exclude traffic fines of less than $25.) 
If yes explain 	_ 
Have YOLI ever been dismissed (fired) or asked to resign from any position? __ 
___________________ . Have you ever worked for our 
Clinical site OR attended our school?  Yes	No__________ 
Education and Training: 
Highest level of Education? 	_ 
Can you read and write the English language? 	_ 
Have you been dismissed from other vocational schools? 	_ 
Have you ever attended Health Career Solutions? 		
If so what program did you take? 	_ 
Deposit paid 	_ 
Balance Due 	_ 
. 
Name of program you are enrolling in 	CNA 	MAA    Phlebotomy 
Start date of program 	_ 
Day 
Weekend (circle one) 

HEALTH CAREER SOLUTIONS 
20600 Eureka Road
Suite # 409 
Taylor, MI 48180 
313-551-5815 
    Thank you Mr. or Ms. _____________________________________________	for taking 
This is the first step in enhancing your educational and career path. We at HCS would like to assist in making his transition for you an exciting one. Our skilled nurses are here to teach you what is required to enter the field of choice. 
	Nurse Assistant Training Program 81 hours DAY 	EVE 	WKED DATE: 
	Phlebotomy Training Program 64 hours DAY 	EVE 	    WKED DATE:
	Medical Administrative Assistant Program 720 hours DAY 	EVE WKED DATE: 

We at HCS require a minimum non-refundable deposit of $100.00 for the nurse assistant 
Program and $200.00 non-refundable deposit for phlebotomy program, and $300.00 non-refundable deposit for the medical administrative assistant program. 
All deposits will be put towards your tuition. You may pay with cash, money order, or credit card (there is a fee for card use). . Please note we do not accept Discover Card or American Express. If you have an emergency that is acceptable, we can move the deposit to the next available class. 	Your deposit today is for$ _____________________If you do not show up for class after the date signed for you forfeit all money. You are expected to show up in class on time, in your uniform. You must have a pen, pencil, and small note pad, and a bag to carry books and hand out in. Space is limited so leave purse in car or place everything in one bag. The total amount due for this class can either be paid now or the first day of class. Your balance is $________________________________________. You will not be admitted to class without the total balance paid in full. If you need a reasonable payment agreement please let us know at time of registration.  ALL fees are due prior to program completion.  There is a payment arrangement fee and you can not take the book home. 
Please keep in mind by signing this form you agree to the above terms and conditions. Consider this your receipt. 
Thank you 
Shateria Boone RN             
Program Director 
	Student Signature _______	Date 	_ 

School Representative 5ignature _________ 

________       Date 

1.	
Health Career Solutions, Inc. 
CLASS RULES PLEASE READ, UNDERSTAND, AND INITIAL NEXT TO THE RULE. IF YOU HAVE A QUESTION, PLEASE DON'T HESITATE TO ASK, BUT RAISE YOUR HAND. UNDERSTAND THAT LIFE RULES AND BASIC RESPECT STILL APPLIES. THE FOLLOWING RULES ARE NOT LIMITED. 
______ No smoking in or around the school/Horizon Building/In Building or the Clinical site. Go to your car and if you must smoke, do not throw your cigarettes on the ground. No hanging around the neighbor or other business doors.  I do understand that there is smoking in front of this building and it is tempting, but while in uniform you represent the school so follow the rules, No Smoking. 
_______ No Cell phone in the class room. No cell phones at the Clinical site. No charging phones or equipment in the class room. No Charging phones or equipment at the clinical site. You can use your phone on your break. No use of cell phones in the hall way of this office building, you may go to the restroom there is a powder room area with chairs to sit.  Respect our neighbors.  On break also go to powder room or your car, we actually don’t want to hear your conversations.  There are no phones provided unless it is an emergency.  

_______You can bring your lunch, but clean up behind yourself. If you bring a drink make sure it has a secure top and when you are done pore the liquid out in the 
toilet and throwaway the cup in garbage can. 

_________If there is no garbage bag in the garbage can, please do not put your trash in, let instructor know so that one can be placed in can. 

________Pleas call the instructors by professional names. For example NURSE BOONE, NURSE HENDERSON, MS. BOONE, MR.T, MR. ROBBINS, etc. 

_________NO GUM IN BUILDING, CLASS ROOM, AT CLINICAL SITE. 

_________Get a book bag to put your book in. If it is damaged (more then it is) you will be responsible for the $60 replacement fee. Remember the book is on the website at healthcareersolutions.org __________________________.

_________________Read all of your material, Your Book, Home work and all handouts. Read before you ask questions. Don't interrogate the instructor, please have educated and well thought out questions. Please give the instructor a chance to get a complete thought out before interrupting with raising your hand. Limit the interruptions we all are here to learn. 

_____________You will have time to practice, the goal is for you to repeat all skills at least 2x's for the instructor after she has demonstrated. You will get practice time. Everyone must participate, this is important for Indirect Care.

_____________Handle all equipment with care if YOU BREAK IT YOU BOUGHT IT!! 

______________You will be dismissed for failing. Lab or Clinical is Pass or fail. Lecture and class you will need an 80%. You must pass all sections to pass the course. 

_________Class starts on time; we will open the door 10 minutes before class. If you are late you are responsible for all information you missed. Do not interrupt the class. If you are going to be late call the school and leave a voice message or text instructor. 

__________Ware clean socks, underwear, and make sure your hair is up. If you are 150lbs or less you will be chosen to participate in the skills. Please when practicing if you weigh more, don't sneak and do it. For your safety. 

______________KEEP YOU'RE FEET ON THE FLOOR! NOT THE CHAIR AND NO SHOES ON THE BED!! 

_____________If you have been approved to make up time then you may 
have to pay a fee. You have 72 hours before the make-up class to pay the fee. $100 per day if approved. There is a $25 late fee if you pay the day of the make-up. All fees are non-refundable. If you are approved to make up a day, you must attend the class you are approved for. If you change the day or fail to show up, you will not be refunded and will be failed and dismissed from the program. 

___________Do not touch the TV, DVD, Cable box, or remote controls please. 

____________When arriving at the Clinical site all students park in the very back and on the far left or right side of the Horizon building. 

__________The only thing you bring to clinical is your ID, one black pen, and keys in pocket. NO PHONE. 

____________You will need a - TB and + background check to go to clinical, so get it done ASAP there are no refunds. TB and back ground check must be turned in by Day 5 of class or you will be dismissed.  

__________Do not apply to work at the facility until you have graduated from the program. 

______________Cover your mouth when you yawn and cough! 
Please control yourself in the class and at the clinical. No load yawns, cough, farts, long stretches in the patient care area.  Go to the rest room or break room. You will have a lunch break and a short break, use it the instructor takes breaks too. So hold all questions to after break. 

__________If you need copies. $15 for receipt $20 for certificate, and we DO NOT keep your background check or TB so make your own copy before handing in to instructor. The photocopier is for office use and copies are $5 in an ER situation. 

____________You must have good hygiene. 

____________If dismissed from the program please go to another school, don't come back here. 

__________If you use the bathroom, please clean up behind yourself. Don't leave your bod y fluids all over the place. 

__________When entering the building please do not announce the weather, we know what it is. Especially at the facility the temperature is adjusted for the resident's not you. 

__________Be in uniform every day! No hair scarf unless it is faith based or stylishly appropriate. No PJ’s.

_______When the instructor is demonstrating a skill STOP, LOOK, AND LISTEN! Do not sit in your chair then ask the instructor questions after about the demonstration you missed! We will document your participation and lack of participation. Pass or Fail for lab. 

________ Wash your hands. 

HEAL TH CAREER SOLUTIONS, INC. 
HEPATITIS B DECLINATION FORM 
The U.S. Department of Occupational Safety and Health (OSHA) have developed standards to protect workers from occupational exposure to blood-borne disease including Hepatitis. As a student, you are at risk of directly contacting body fluids. Because of the risk, Health Career Solutions recommends that all students be vaccinated against Hepatitis B. 
All students enrolled in clinical courses in the Health Career Solutions Nurse Assistant Training, Phlebotomy Training, a Medical Administrative Assistant must either receive Hepatitis B vaccination or sign the following declination statement before attending any clinical practicum in the program. 
I hereby release Health Career Solutions, its Board Members and personnel, and any clinical facility at St. Jude’s or Advantage Living Southgate which I train from any liability for any consequences to me or any claims arising out of or related to my decision not to be vaccinated. 
I hereby agree to indemnify all of the above persons and organization for any and all claims, including attorney fees and costs, which may be bought against any of them by anyone claiming to have been injured as a result of my decision. 
	Student name: 	_ 
	Student signature: 	_ 
	Date: 	_