FALL 2016
Application for Admission to AHS 114 – Nursing Assistant
READ CAREFULLY BEFORE APPLYING
*Students applying for AHS114 must:
1. Be a student of record at Yavapai College, have a Y# and obtain an YC issued student photo ID.
2. Successfully complete:
a. Reading proficiency test at the Yavapai College Testing Center (928-776-2200) OR provide Yavapai College Office of
Registration with proof of successful completion of 12 college credits AND
b. Successful completion of MAT082 or higher or a satisfactory score on the mathematics skills assessment. (New AZ BN
requirement) NOTE: The YC enrollment system will not allow students to enroll without requirements a and b.
3. Students are accepted into AHS114 on a first come basis of completed applications. Fall ‘16 registration begins April 11, 2016.
4. Students are notified by email with instructions for the registration process for AHS114 and the random drug test*.
* Allied Health students who participate in clinical experience are tested for illegal drug use. Students with a positive drug
Screen are not permitted to take Allied Health courses for a minimum of one year. A student with a history of drug-related
convictions may be disqualified from participating in an internship or clinical experience and may be ineligible for
certification and/or licensure. Please meet with an academic advisor for further direction.
HEALTH REQUIREMENTS FOR NURSING ASSISTANT STUDENTS
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Near and distant vision, corrected if necessary, adequate to perform client activities and use equipment.
Hear face-to-face speech, including clients or staff using masks. Hear when using telephone or intercom.
Communication skills adequate to communicate verbal and written messages clearly, in English.
Lift 50 pounds
Walk independently. Stand for several hours.
Carry supplies, push and pull equipment.
Manual dexterity involving hands and fingers to write and use small equipment.
Able to work with hands in water and wash hands frequently.
Able to care for clients with infectious diseases.
Free of infection, i.e., TB, active skin lesions. Excludes short term conditions such as problems responding to antibiotic or a cold.
Mental and emotional stability.
Physical conditions such as diabetes, seizure disorders, cardiac disease, or emotional problems are controlled.
Arizona State Board of Nursing – Information to know when applying for nursing assistant certification.
CITIZENSHIP/NATIONALITY/ALIEN STATUS DOCUMENTATION
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Federal law, 8 U.S.C. § 1641, and State law, A.R.S. § 1-501, require documentation of citizenship or nationality for certification. If the
documentation does not demonstrate that the applicant is a United States citizen, national, or a person described in specific categories, the
applicant will not be eligible for certification in Arizona. All applicants must submit documentation regarding their citizenship/nationality/alien
status with their application. See attached list A & B for specific documentation required.
FINGERPRINTING
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According to A.R.S. § 32-1606(B) (16), each applicant for initial licensure or certification is required to submit a full set of fingerprints. If you have
not submitted a fingerprint card with your application, one will be mailed to you after we receive your application. It is important for you to use
that specific fingerprint card because we have Arizona State Board of Nursing information printed on the card. It can take 4 to 5 weeks to
receive fingerprint results. You will not be certified until results are received. A copy of a fingerprint clearance card cannot be substituted for
this requirement.
FELONY CONVICTIONS
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According to A.R.S. § 32-1606(B), an applicant for certified nursing assistant is not eligible for certification if the applicant has any felony
convictions and has not received an absolute discharge from the sentences for all felony convictions. The absolute discharge from the sentence
for all felony conviction(s) must be received 3 or more years before submitting this application. If you cannot prove that the absolute discharge
date is 3 or more years, the Board will notify you that you do not meet the requirements for certification.
I have read and understand, not only what documentation is required when submitting the application (Negative TB test, CPR for Healthcare
Providers, AZ DPS Fingerprint Clearance card & photo ID), but also understand the health requirements for the nursing assistant program. I have read
the above information about the Arizona State Board of Nursing mandated requirements regarding citizenship, nationality, alien status
documentation, finger printing and felony convictions.
(Applicant’s Signature)
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(Date Submitted)
FALL 2016
Application for Admission to AHS 114 – Nursing Assistant
Fall 2016 Registration for Nursing Assistant begins April 11, 2016
Applications are accepted from 4/4/16 – 8/22/16
Submit by fax to (928-777-3144) or scan application/documents and email to: [email protected]
Please print clearly or type:
Lk;lk’;lk ’;lk
Name:
Yavapai College Y#*:
Mailing Address (Street or P. O. Box):
City:
State:
Zip:
Phone:
E-mail:
DOB:
Emergency Contact Name:
Phone:
IMPORTANT: Students will be notified of admission and provided with further instructions at the email address provide above.
Students will be given a deadline to register. If you miss the deadline, you will forfeit your seat to the next student on the waitlist. Please check
your email daily, failure to do so may lead to a drop from the program. Make sure your browser accepts yc.edu mail.
Are you a Veteran? Yes_____
No_____
When do you plan to apply to the nursing program? _______________________
Prescott Campus: Monday and Wednesdays - August 22 – December 7, 2016
___ CRN# 30881 – Mon. 8:00 a.m.-1:00 p.m. Lecture; Wed. 8:00 a.m.-11:00 a.m. Lab
___ CRN# 31278 - Mon. 8:00 a.m.-1:00 p.m. Lecture; Wed. 12:00 noon -3:00 p.m. Lab
Prescott Campus: Tuesday and Thursdays - August 23 – December 8, 2016
___ CRN# 30888 – Tues. 10:00 a.m.-3:00 p.m. Lecture; Thurs. 9:30 a.m.-12:30 p.m. Lab
___ CRN# 31279 - Tues. 10:00 a.m.-3:00 p.m. Lecture; Thurs. 1:00 p.m.-4:00 p.m. Lab
Fax to: Yavapai College, Allied Health at 928-777-3144 OR SCAN APPLICATION AND EMAIL
TO: [email protected]
Attach these documents to complete the application:
Incomplete Applications will not be processed
State of Arizona Department of Public Safety Level-One Fingerprint Clearance Card (front & back of card)
TB skin-test or chest X-ray results from physician’s office (must not expire during the course).
CPR for Healthcare Providers card (front & back of card) CPR card must not expire during the course.
Online CPR certification is not accepted. Card must read: CPR for Healthcare Providers or CPR PRO
Copy of Photo ID (example: Yavapai College ID preferred or other photo identification).
Important Additional Information
When the application is approved, you will receive an email (sent to the address on this
application) from Allied Health giving provisional acceptance. Provisional acceptance is subject to
passing a random drug screen. Students with provisional acceptance will be directed to prepay for
the drug screen at: www.CertifiedBackground.com at a cost of $59.00. Students will be directed
by Allied Health when and where to complete the drug screen.
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FALL 2016
Application for Admission to AHS 114 – Nursing Assistant
Application is considered incomplete without all of the above documentation
including the Y# and will be rejected until complete.
FAX TO: Yavapai College, Allied Health at 928-777-3144
OR
SCAN APPLICATION AND EMAIL TO: [email protected]
Phone: 928-771-6122
5.000 Credits
Admission to AHS114 is by application. Contact the Allied Health office for information or check the Nursing
Assistant website for application and requirements at http://www.yc.edu/alliedhealth/nursing-assistant
Schedule: Nursing Assistant – CRN# 30881 - AHS 114 – 102
Meeting
Lecture Class
Skills Class
Clinical
Meeting Dates
Aug. 22 – Dec. 5, 2016
Aug. 24 – Dec. 7, 2016
Oct. 26 – Nov. 30, 2016
Meeting Days & Times
Mondays
8 a.m. to 1 p.m.
Wednesdays 8 a.m. to 11 a.m.
Wednesdays 6 a.m. to 3:30 p.m.
Schedule: Nursing Assistant – CRN# 31278 - AHS 114 – 104
Meeting
Lecture Class
Skills Class
Clinical
Meeting Dates
Aug. 22 – Dec. 5, 2016
Aug. 24 – Dec. 7, 2016
Oct. 26 – Nov. 30, 2016
Meeting Dates
Aug. 23 – Dec. 6, 2016
Aug. 25 – Dec. 8, 2016
Nov. 3 – Dec. 1, 2016
Meeting
Lecture Class
Skills Class
Clinical
Meeting Dates
Aug. 23 – Dec. 6, 2016
Aug. 25 – Dec. 8, 2016
Nov. 3 – Dec. 1, 2016
Meeting Place
Bldg. 2, Room 211
Bldg. 2, Room 207
Clinical Site (TBA)
August 23, 2016 to December 9, 2016
Meeting Days & Times
Tuesdays
10 a.m. to 3 p.m.
Thursdays 9:30 a.m. to 12:30 p.m.
Thursdays 6 a.m. to 3:30 p.m.
Schedule: Nursing Assistant – CRN# 31279 - AHS 114 – 105
Meeting Place
Bldg. 2, Room 211
Bldg. 2, Room 207
Clinical Site (TBA)
August 22, 2016 to December 9, 2016
Meeting Days & Times
Mondays
8 a.m. to 1 p.m.
Wednesdays 12 noon to 3 p.m.
Wednesdays 6 a.m. to 3:30 p.m.
Schedule: Nursing Assistant – CRN# 30888 - AHS 114 – 103
Meeting
Lecture Class
Skills Class
Clinical
August 22, 2016 to December 9, 2016
Meeting Place
Bldg. 2, Room 211
Bldg. 2, Room 207
Clinical Site (TBA)
August 23, 2016 to December 9, 2016
Meeting Days & Times
Tuesdays 10 a.m. to 3 p.m.
Thursdays 1 p.m. to 4 p.m.
Thursdays 6 a.m. to 3:30 p.m.
Meeting Place
Bldg. 2, Room 211
Bldg. 2, Room 207
Clinical Site (TBA)
Yavapai College is an affirmative action/equal opportunity institution. For Yavapai College’s nondiscrimination statement, visit
www.yc.edu/aa-eeo. A lack of English language skills will not be a barrier to admission and participation in the programs of the
college.
Yavapai College es una institución de oportunidades de acción/igualdad afirmativa. Para la declaración de no discriminación de
Yavapai College, visite www.yc.edu/aa-eeo. La falta de conocimiento del idioma inglés no será una barrera para la admisión y
participación en los programas de la universidad.
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FALL 2016
Application for Admission to AHS 114 – Nursing Assistant
Additional Information from the Arizona State Board of Nursing
Starting June 13, 2016 all each graduating students will need to have proof of legal presence in the United
States on file with D and S (Headmaster) in order for the student to be scheduled for the manual skills and
written CNA exams. All Nursing Assistant training programs will need to collect the document, photocopy
or scan the document and upload it to Headmaster upon registration or program completion. Ideally, this
identification document should be the same as the ID document(s) the student uses for state testing (e.g.
AZ driver license or passport). The name on the document should exactly match the name entered in the
system. A comprehensive list of documents acceptable for proof of legal presence is available
at: http://azbn.gov/licensure-certification/citizenship-alien-status/
On July 1, 2016, all CNAs who were certified by the Arizona State Board of Nursing (Board) before July 1,
2016 will be issued a license to practice as a nursing assistant (LNA). The $100 initial fee for licensure as a
nursing assistant will be waived for all nursing assistants certified before July 1, 2016. This license will
expire on the same day and year as the previous CNA certificate was due to expire. To renew the LNA
license, a $50 fee will be charged. A nursing assistant who does not want to convert his/her CNA to an LNA
may request to have the LNA removed and be listed on the CNA Registry only. An LNA who does not renew
the LNA, will be required to renew the CNA to remain on the CNA Registry. Please visit our website (insert
link) for additional information.
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5/31/16rev.