Infinity School Application

Step 1 of 2

Personal Information

Date of Application(Required)

First Name(Required)

Last Name(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

City(Required)

State(Required)

Zip(Required)

Email(Required)

Phone number(Required)

Last 4 of SS#

Sex(Required)

Female

Male

Prefer not to say

Other

Date of Birth(Required)

Desired Course(Required)

New Jersey CNA to New Jersey CHHA Conversion Course

New Jersey CHHA Certification

Pennsylvania Home Health Aide Certification

Professional CEU’s

Other

Enrollment Month(Required)

Disclaimer and Signature

I UNDERSTAND AND AGREE TO FULFILL THE FOLLOWING CONDITIONS OF MY ENROLLMENT IN THE NEW JERSEY CARE-PRO BLENDED HOMEMAKER-HOME HEALTH AIDE TRAINING PROGRAM, ADMINISTERED BY INFINITY HEALTH CARE SERVICES. A complete 76 hours of initial state mandated hours of classroom and lab is required for completion of the program in order to obtain certification 60 hours of approved online course and 16 hours of clinical instruction in a skills laboratory or patient setting which will be held. ( SEE WEBSITE FOR LOCATION) Student is responsible for all fees to fulfill the 76-hour requirement due two weeks before classes begin. A deposit of half of the course fee of $250 is due at registration for non employees of Infinity. A deposit of $175 is due at registration for employees of Infinity HCS. ( can be deducted from payroll, but must be requested) A course outline and calendar of dates will be given upon admission with instructions. Information can also be found on our website at www.infinityhealthcareservices.com COURSE FEE (fees do not include the $80 fee to the NJ Board of Nursing) Non-Employee $550 with a deposit of $250 at the time of registration Infinity Healthcare Services, LLC Employee $350 (who have longevity.) REFUND POLICY Infinity Healthcare Services reserves the right to cancel the CHHA classes and refund all fees in the event of insufficient registration or rollover to next class. Students who cancel their registration will receive a 90% refund if a one week notice is given. This does not include the fees to the board of nursing.

Student Full Name(Required)

First Last

Date(Required)