* = Required Information
Personal Care Aide Nurse Aide
32 hr Medication Aide 68 hr Medication Aide
PCA/68 Med Aide COMBO 68 Med Aide/Nurse Aide COMBO
Yes No
Yes No
Yes No
Person to Be Notified In Case Of Emergency:

Yes No
Yes No

Sworn Disclosure Statement: Section 32.1-126.01 of the Code of Virginia requires that any persons desiring work at a Nursing Facility provide the hiring facility with a sworn disclosure or affirmation disclosing any criminal convictions or pending criminal charges, whether within or without the Commonwealth of Virginia. The law prohibits licensed Nursing Facilities from hiring individuals convicted of the following: murder, abduction for immoral purposes, assaults and bodily wounding, arson, pandering, crimes against nature involving children, taking indescent liberties with children, abuse and neglect of children, failure to secure medical attention for an injured child, obscenity offenses, abuse or neglect of an incapacitated adult. However, applicants convicted of one misdemeanor crime not involving abuse or moral turpitude may he hired provided 5 years has elapsed since the conviction. Any person making a false statement on this form regarding any criminal offense shall be guilty upon conviction of Class I misdemeanor. Further dissemination of the information provided pursuant to this section is prohibited other than to a federal or state authority or court as may be required to comply with an express requirement of law for such dissemination.

Regulations 18VAC90-‐25-‐20-‐B-‐3: state that each student applying to or enrolled in any Nurse Aide education program shall be given a copy of applicable Virginia law regarding criminal history records checks for employment in certain health care facilities, and a list of crimes which pose a barrier to such employment (See Guidance Document 90-55 under Educational Training Program tab at http://www.raspberryhilladc.com/adult-day-care-educational-training-program). *Any person who has been convicted of a felony or misdemeanor may not be eligible for licensure as a certified nurse aide or a medication aide in VA. By signing this I agree I have read and understand the Sworn disclosure Statement/link attached for barrier crimes, Guidance Document 90-55 that is explained above. Any person who uses alcohol or drugs excessively may also be ineligible for licensure. (Section 54.1-‐3007 Code of Virginia). Please contact the Board of Nursing 804-367-4515 for further questions about crimes.

Yes No
Please list 3 professional references not relatives that can verify your character. (Agency will call.)

* It is my understanding that I will not be considered for admission to the Raspberry Hill Healthcare Training until I have submitted all documents as specified by the Program. I further agree to inform the program coordinator of any changes in my address and/or legal name or plans to attend the Raspberry Hill Healthcare Training. I understand that withholding information requested in the application or giving false information on any documentation may make me ineligible for admission to/or continuation in the Raspberry Hill Healthcare Training. The Program will be released from any and all claims arising out of such investigation and testing. I understand that any false statements or omissions in response to the questions relating to convictions may result in refusal to admit me to the Raspberry Hill Healthcare Training. I understand that any background check will comply with the Fair Credit Reporting Act. I further understand that an applicant who meets all requirements is not guaranteed admission into the program. I understand and agree that this is not an application for employment with Raspberry Hill Healthcare Training .

Tuition: Checks payable to:


Raspberry Hill Adult Daytime Center
2617 Elk Valley Rd.
Forest, Va. 24551
Online credit/debit card payment through PayPal at www.RaspberryHilladc.com
Personal Care Aide (Certified) Nurse Aide
32 hr Medication Aide Combo Personal Care Aide/68 hr Medication Aide-State (RMA)
(Combo Nurse Aide/68hr Medication Aide Class) (AHA BLS CPR, required for both classes (68 hr Med Aide, Nurse Aide)
You must successfully pass the Nurse Aide Course to take the Medication Aide Class. Medication Aide tuition will be reimbursed if you don’t successfully pass the Nurse Aide Class. I understand that by signing this application I acknowledge receipt of and an understanding of the Guidance Document 90-55 and the Barrier Crimes List therein. I will authorize the Raspberry Hill Healthcare Training to conduct a Criminal background investigation and sexual offender registry before acceptance into the program.

PHOTO RELEASE


I, (student’s name) * give my permission for Raspberry Hill Adult Daytime Center to use a picture or video taken of Education Classes (Personal Care Aide, Certified Nursing Assistant ,Medication Aide, CPR, First Aid, that are done at Raspberry Hill Adult Daytime Center for the following use: Pictures and Videos taken by Raspberry Hill Adult Daytime Center will be posted on the Raspberry Hill Adult Daytime Center Face book page, or website of Raspberry Hill Adult Daytime Center, www.Raspberryhilladc.com. These pictures/videos will be for the sole purpose of demonstrating the Education classes and promoting them to the Community.

For good and valuable consideration and intending to be legally bound hereby, the undersigned agrees and consents that any photographs, films, videotapes, voice recordings and/or testimonials of her or him, taken or made by may in any manner be used, published, displayed, dealt in and copyrighted by the organization, and that all materials and rights connected herewith are the exclusive property of Raspberry Hill Adult Day Time Center.

The undersigned further agrees to release for herself or himself their heirs, executors and administrators of its officers, agents, employees, advertising agents, successors and assignees, from any obligation or liability and from any and all claims for libel, slander, invasion of privacy, compensation or any other claims based on the use or exhibition of said material.

Tuition Refund Policy

Tuition Refund and payment policies for facilities and general public:

All classes:

*Nurse Aide/68 Medication Aide Program/PCA, 32hr Medication Aide, Direct Client Course:

  • Payment is DUE for all classes upon application deadline. This amount must be received by application deadline or your spot cannot be reserved.
  • Facilities if there is NO application deadline please pay promptly upon receiving invoice so the student’s spot will be secured. Failure to pay in a timely manner will result in non-enrollment for the student. Certificates of completion will not be issued to the student if there is any outstanding balance.
  • BLS CPR is included in facility packages if a student already has CPR the tuition price remains the same, no adjustments to price will be made. Also if a student (facilities only) drop out of the class for any reason other than medical necessity (MD order), death in family the money is not transferable for another student for any reason in future classes. If there has been a death in the family or MD reasons with a MD note stating these reasons, the student with administrative approval may be able to attend the following class only. Space is limited and depending on acceptance from administration. Please contact the office for further details.
  • Cancellations must be written 14 days in advance of first day of class in order to get a refund on the class tuition. If an agreement has been made and confirmed by an agency that they are paying for a student that is attending our classes and the student drops out or doesn't attend class for any reason and cancel within the 14 days prior to class. Payment is still expected and the agency is held liable for payment.
  • Full payment is expected by the application deadline. Payment plan is not offered any longer privately. Paypal and Blisspay is an option as we accept both as well as credit cards.
  • If you have a medical need with a MD order/death in family and have to stop attending classes we will make every effort to see if you can come in on the next class but it’s not definitive it’s based on space and administrative approval for none payment of next class. If you fail the course you will have to pay the same tuition price for the next class. If payment has been received and you are not eligible for a refund (passed deadline for a refund) none of your payment can be redeemed for any student in the present class or future class.

I agree with the terms and condition