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SWIHSA Application

Personal Information
Name(Required)
MM slash DD slash YYYY

Contact Information

Home Address(Required)

Emergency Contact Information

Name(Required)
Home Address(Required)

Have you previously been enrolled in a course at SWIHSA?(Required)
Are you applying for the CNA or QMA course?(Required)
How did you hear about the SWIHSA program?
If you’re currently employed at a senior care facility?

In the event of an emergency, I hereby give SWIHSA the authority to call 911 and seek emergency care on my behalf. I also give permission to call my emergency contact person and release medical information that is necessary for me to receive appropriate medical care.
Clear Signature
Clear Signature

By submitting this application, I acknowledge that I have answered the above questions to the best of my knowledge.

This field is for validation purposes and should be left unchanged.