Admission Checklist

1.	____      Application complete
2.	____      Choose course date/ time/ location 
3.	____	    Sign up for CPR class if you don’t already have a card
 	__________ (class date)
4.	_____     Background check complete (See last page for details go to viewpoint  screening  and find the school Family 1st of Virginia )
5.	____      Student pricelist (choose items in which you wish to purchase)
6.	____	  Code of conduct (dress code/ tardy/absence policy)
7.	____    Cancelation policy
8.	____    Refund policy
9.	____    Copy of required documents
•	CNA/ PCA certificate     ____
•	2. Copy of valid ID         ____
•	3. PPD/ Chest x-ray         ____
•	4. CPR/First Aid $ 75      ____
 ___    Payment Agreement completed and signed
 (You CANNOT go to clinical unless your balance is paid in FULL.)
Student Information:

STUDENT NAME:	HOW DID YOU HEAR ABOUT US?	
ADDRESS:	CITY/STATE/ZIP:	
TELEPHONE: (H)	CELL:	
EMAIL:	WORK:	
SOCIAL SECURITY # (Last 4 digits):	DATE OF BIRTH:	
EMERGENCY CONTACT:	CELL:	
RELATIONSHIP:		

PROGRAM INFORMATION: (for office use only)

DATE OF ADMISSION:				PROGRAM/COURSE: 	 

PROGRAM START DATE:  	

ANTICIPATED END DATE:  	

□	DAY		□ EVENING

TIME OF DAY/EVENING CLASS BEGINS:  	  	 

TIME OF DAY/EVENING CLASS ENDS:  	

NUMBER OF WEEKS:  	

TOTAL CREDIT/CLOCK HOURS: 	

EDUCATION

Name of High School or College	

Years attended	

Degree/Diploma	

Major	

				

Other Trainings	Certificate Received	Date	

REFERENCES
Please list 2 Non-Relative persons you have known for at least a year.

Reference 1:
Name: 	 Day Phone: _ 	 

Relationship: 		 Year(s) known: 	

Reference 2:
Name: 	 Day Phone: _ 	 

Relationship: 		 Year(s) known: 	

I hereby certify that all statements, answers, and representations on this form, are true, complete and accurate.
Print Name: 	
   Signature:		Date: 	

CANCELLATION AND REFUNDS Policy

1.	Student Applicants who cancel before or on the first day of class will be charged a $100.00 non-refundable fee to cover the cost of enrollment processing.

2.	Student who withdraws or is terminated after three (3) classroom sessions     WILL NOT receive their down payment. If you have paid in full, please refer to to the REFUND POLICY. If grant you will receive a refund, but MINUS your down payment and REFUND SCALE.
3.	Please note that a refund will come in the form payment method, and takes 7-14 business days to process.

Print Name:  	

Date: 	

Signature: 	

Administrator Name: 	

Date: 	

Administrator Signature: 	

Refund Policy

Will I be able to receive a refund for the Class I am taking?

There are no refunds granted once an applicant has applied for a class and has begun making payments. The only exception would be if a background check returned with a barrier crime. Family 1st of Virginia Healthcare and Safety Training Center will make every effort to assist each student with arrangements to accommodate his/her scheduling needs in reference to re-scheduling classes and payment. Family 1st of Virginia Healthcare and Safety Training Center, at its sole-discretion, has the right to revisit this policy. If a refund is given, the process will take 7-14 business days to make a decision, and you will be notified via phone and a check will be mailed. If you have made any partial payments, you will not receive any refund. Refunds only granted to those who paid in full.  (Please see guidelines below).

Refunds will be returned as follows:

Class time 
days	Amount of Refund
Only if you Paid in full doing the time of enrollment. 	
1-3	Everything-minus down payment 	
4-6	60%	
7-9	40%	
10-12	20%	
13-20	None
(Please speak with office to re-schedule another class.)	

Signature of Student	Date

Signature of School Official	Date

CRIMINAL DISCLOSURE AND AGREEMENT

       	I______________________________   have been made aware and understand the ramifications of the following offenses, in regard to my enrollment and progression in a Family 1st of Virginia Training program as it relates to me:

1.	Barrier Crimes 
2.	Felony and/or misdemeanor convictions(s),
3.	Guilty plea or NO CONTEST to any crime which indicates that one is unfit or incompetent to practice as a health care provider or that one has deceived or defrauded the public, and/or
4.	Parole violation

Before I can enroll or continue in courses with a clinical component, any crime of which I have been convicted must be disclosed to FAMILY 1ST of VIRGNIA Healthcare and Safety Training Center

List criminal offenses here (YOU WILL STILL HAVE TO DO A BACKGROUND CHECK)

1._____________________________________________________________________________

2._____________________________________________________________________________

3._____________________________________________________________________________

Clinical agencies have the right to refuse a clinical practicum for students in their facilities. Therefore, I may be unable to successfully complete the program because clinical objectives cannot be met, and I will be dismissed from the program.

I release Family 1st of Virginia Healthcare and Safety Training Center of any and all liabilities. I agree and promise Family 1st of Virginia Healthcare and Safety Training Center that I will not seek employment in the healthcare industry while any MISDEAMNOR/ FELONY are pending on my criminal records.

Student Signature	Date

Student Print Name

Administrator Signature	Date

Complaint/Grievance Procedure Policy

If you have any problems or complaints while attending Family 1st of Virginia Healthcare and Safety Training Center please follow the procedure outlined below: First, discuss the issue with your Instructor. The instructor will make every effort to resolve the issue. However, if you are not completely satisfied with the result, you should submit a written complaint that is signed and dated by the student. An appointment will be scheduled with the school Administrator, James Gough, in order to make every effort to resolve the complaint. The complaint and its results will be documented and kept on file.

Non- Discrimination Policy

Family 1st of Virginia Healthcare and Safety Training Center is committed to the principle of equal opportunity in education and employment. The Institute does not discriminate against individuals on the basis of race, color, sex, sexual orientation, gender identity, religion, disability, age, genetic information, veteran status, ancestry, or national or ethnic origin in the administration of its educational policies, admissions policies, employment policies, or any other characteristic protected under applicable federal or state law.

Pregnancy Policy

If you know that you are pregnant at any point during your CNA/MED TECH training.  For your safety you must disclose this during enrollment, and you must make your instructor aware you also have a note from your doctor stating that you are healthy and able to lift at 50 LBs, before you may start.  Failure to do so may result in you being dropped out of the program. _______ (Initials—Women Only)

Dress Code Policy

Students must follow dress code rules. You must wear a neat, clean and pressed uniform every day of class. You must also wear your required color uniform

1. CNA-Royal Blue
2. MED TECH-Red
 3. PHARMACY TECH- Gray

						Code of Conduct Policy 

1.	Be responsible and accountable for his/her personal and professional judgments and action.

2.	Take action when health care and safety are at stake such as reporting dishonesty, unethical behavior in the classroom or clinical site, sharing of clinical personal clinical exams with other students, etc.
3.	Be academically honest. Dismissal from the program may result if there is a breach in this contract.
4.	Be free from impairments or the smell of illegal substances. Any nursing student found to be under the influence, or the smell of an illegal substance will be subject to disciplinary actions including dismissal from the site/facility, criminal prosecution, and/or referral to an assistance or rehabilitation program. All these consequences will take place at the discretion of faculty.
5.	Refrain from using cell phones and other forms of electronic communication while in the classroom and in the clinical site.
6.	Will only smoke in designated areas at designated times.
7.	Will not chew gum during clinical sessions.
8.	Any form of disrespect towards the school or its instructors will be grounds for termination.

Absences and Tardiness Policy

You are responsible for notifying the instructor in advance of any absence or tardiness from class.  
  
1. Any (un) excused absence or tardies are grounds for termination from the program.
2. Additional fees, of $50.00 per session, for private tutoring, make-up missed or clinical day(s), to meet the program requirements for completion. 
3. If you have more than two unexcused tradies and more than one unexcused absence                   
   YOU WILL NOT GO TO CLINICALS. 
4. It is the student’s responsibility to make arrangements to make up missed time, in order to be eligible to go to clinical and finish the program.
5. If absent, the student is responsible for obtaining all class notes, announcements, and assignments for the day or day’s the student missed. ______(Initials).

Termination Policy:
Students must establish and maintain a record of good standing throughout their program. Family 1st of Virginia Healthcare and Safety Training Center, LLC reserves the right to dismiss/terminate a student for any of the following reasons:  More than two (2) unexcused tar dies, More than one (1) unexcused absent days, failure to maintain an 80% in classroom and clinical portion of the program, disruptive or disorderly conduct, cheating, and non-payment of tuition.  _________ (Initials). 

Employment Assistance

Family 1st of Virginia Healthcare and Safety Training Center does not guarantee job placement to graduates upon program completion or upon graduation. Ultimately, the student is solely responsible for securing employment. We will provide employment assistance upon graduation. The student has the choice to work with any employment agencies or organizations they choose. ______ (Initials)

Rescheduling Program Start Date

Family 1st of Virginia Healthcare and Safety Training Center reserves the right to reschedule the program if there are not enough students enrolled in a program.  If there are NOT ENOUGH students enrolled in any particular program.  You will be contacted the Friday before class starts if class has to be canceled. Please be mindful that you will be asked to push back your class date.  Also, the clinical site may cancel our expected clinical date due to unforeseen circumstances. Please be mindful that this is not the fault of Family 1st of Virginia, and we will work as quickly as possible to reschedule a date. 
***Please be aware that up most be able to lift + 50LB, stand, push and pull and verbally comprehend the information taught during the class, and for the medication tech program you must be able to read and write. If you don’t think you are able to meet these requirements, please make the enrollment advisor aware. 

We thank you in advance for your cooperation.

Student Signature	Date

Student Print Name

Requirements to Attend Clinical

1.	Satisfy all financial obligations prior to attending.
2. A current copy of Student’s PPD/ Chest X-ray must be on file.
3. Criminal Background check must be on file. 
4. A valid copy of CPR & First Aid Certification must be on file.
5. Covid-19 needed only for clinical site
6. A passing grade of 80% in an enrolled program.
7. A minimum attendance hours logged (based per program)
8. Student must wear ironed scrub uniform, name badge, and have blood pressure cuff & stethoscope, and a   watch with a second hand to attend.

Certification and State Board Testing Requirements

1. Along with all the items listed in “Requirements to Attend 
2. Earn a “Satisfactory” clinical performance from 
I	agree to the above-stated requirements for the Course and I understand that if the requirements are not fulfilled as stated above, I may not attend Clinical nor receive a Completion Certification until they are fulfilled.

Missed Clinical days for non-compliance or tardiness will be assessed a minimum of fifty ($50.00) per missed day and will be required to be made up. It is my responsibility to reschedule clinical day(s) with an Instructor.

Student Signature	Date

Student Print Name

_______________________________________                             _______________
Administrator                                                                                                Date

General Photography Release
I hereby authorize (Family 1st of Virginia Healthcare and Safety Training Center), hereafter referred to as “Company,” to publish photographs taken of me during my class and clinical instruction, and my name and likeness, for use in the (Family 1st of Virginia Healthcare and Safety Training Center)'s print, online and video-based marketing materials, as well as other Company publications.
 
I hereby release and hold harmless (Family 1st of Virginia Healthcare and Safety Training Center) from any reasonable expectation of privacy or confidentiality associated with the images specified above. 
 
I further acknowledge that my participation is voluntary and that I will not receive financial compensation of any type associated with the taking or publication of these photographs or participation in company marketing materials or other Company publications. I acknowledge and agree that publication of said photos confers no rights of ownership or royalties whatsoever. 
 
I hereby release (Family 1st of Virginia Healthcare and Safety Training Center), its contractors, its employees, and any third parties involved in the creation or publication of marketing materials, from liability for any claims by me or any third party in connection with my participation. 
 
Authorization Yes_____ I authorize (please fill out information below) or NO______
 
Printed Name: ____________________________
 
Signature: ________________________________ Date: ______________________
 
Street Address: ________________________________________________________
 
City: ____________________________ State: ________ Zip: ___________________

Financial Aide Options.  Please check an option	

Please check the box that applies to you.
	
Bill Me Later (line of credit from Afterpay.  This is subject for credit approval from Bill me Later).  To start the process please visit family1stofva.com website. Visit Afterpay.com for more details.

Tuition Payment in Full

Payment Plan (See next page for details)

VEC Unemployment Workforce Occupational Skills Training

Chesterfield Resource Workforce Center 
7333 White pine Road 
Richmond, VA 23237 
Chesterfield Airport 
Complex
Comprehensive (804) 271-8510 

Henrico East Resource Workforce Center 
5410 Williamsburg Road 
Sandston, VA 23150 
Across from Richmond 
International Airport 
Satellite (804) 226-0885 

Richmond Resource Workforce Center 
6301 Midlothian Turnpike 
Richmond, VA 23225 
Across from Pep Boys Comprehensive 
(804) 675-9910 

Other (social services, trade program, Department of Rehab, etc…..)           	 	______________________________________________

   	
Student Pricelist

ONLY 
FOR 
Work Program
Package 1	Package 2	
Background	
CPR		Background
CPR
Textbook
	
Total: $67.000 	Total: $127.00	
		
Package 3	Package 4	
Background
CPR					
Book		
Stethoscope	
Blood Pressure Cuff	Background
CPR			
Book		
Stethoscope	
Blood Pressure Cuff
TB Screening	
Total:  $157.00	Total: $185.00	
		
Package 5	Package 6	
Background
CPR					
Book		
Stethoscope	
Blood Pressure Cuff
TB Test
Uniform (1 Set)	Background
CPR				
Book		
Stethoscope	
Blood Pressure Cuff
TB Test
State Board Test 
Uniforms (1 set)	
Total:$225.00	Total: $425.00	

Payment Agreement

I,	(Student Name) do hereby agree to the following payment agreement for the ________________________________ (Program Name) Family 1st of Virginia Healthcare and Safety Training Center.

Total Tuition:	$ 	

Down Payment	$ 	

Date: ____________

Received by: 	

Balance Due	$   	       

Payment Schedule:			(#) Payments of $ 	Each

Due Date #1: 	

Amount Due: $ 	

Due Date #2: 	

Amount Due: $ 	

Due Date #3: 	

Amount Due: $ 	

The balance due may be paid in full at any time prior to the due dates. 

PAID IN FULL___________	Received by: 	______________

Payments must be paid on time according to the above indicated schedule. Past due payments will be assessed a ten percent (10%) late fee.

The balance due must be paid in full before the student attends clinical. Students will not receive a Program Certificate until all fees are paid. If you are being sponsored by an Nursing Agency the Certificate will be given and delivered to the Sponsoring Nursing Agency. You will not receive a copy.  This includes any make-up day fee(s), subject to a minimum of fifty dollars ($50.00) per session.

I have read, understand and agree to the above terms and conditions. Student Name (Print): 	 
  Student Signature: __________________________________                           

NOTICE TO STUDENTS

This agreement is a legally binding instrument. Both sides of the contract are binding only when the agreement is accepted, signed, and dated by the authorized official of the school.
  If requested, Student is entitled to an exact copy of this agreement and any disclosure pages signed.
This agreement and the school catalog constitute the entire agreement between the 
Student and Family 1st of Virginia Healthcare and Safety Training Center
The school does not guarantee the transferability of credits to a college, university or institution. Any decision on the comparability, appropriateness and applicability of credit and whether they should be accepted is the decision of the receiving institution.

CONTRACT ACCEPTANCE

I, the undersigned, have carefully read and understand this entire agreement. It is further understood and agreed that this agreement supersedes all prior or contemporaneous verbal or written agreements and may not be modified without the written agreement of the student and the School Official. I also understand that if I default upon this agreement, I will be responsible for payment of any collection fees or attorney fees incurred by Family 1st of Virginia Healthcare and Safety Training Center. My signature below signifies that I have read and understand all aspects of this agreement and do recognize my legal responsibilities in regard to this contract.

Signature of Student	Date

Signature of School Official	Date

REPRESENTATIVE CERTIFICATION

I hereby certify that	has been interviewed by me and in my judgment, meets all requirements for acceptance as a student in the  	     (Program Name) at Family 1st of Virginia Healthcare and Safety Training Center, as described in the school information package. I further certify that there have been no verbal or written agreements or promises other than those appearing on this agreement.

Signature of School Official	Date