SWIHSA Application

Personal Information
MM slash DD slash YYYY

Contact Information

Home Address(Required)

Emergency Contact Information

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.

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.