VICTOR VALLEY COLLEGE
DIRECTIONS FOR SUBMITTING A COMPLETE APPLICATION FOR THE
CERTIFIED NURSING ASSISTANT COURSE
SUMMER 2016 APPLICATION
All applications are evaluated for the elements listed below. As many as thirty (30) qualified students
may be chosen via random selection for the Summer 2016 Certified Nursing Assistant Course. It is
very important that your application is legible and complete.
Print and submit to the address below.
Applications may be mailed or hand delivered to:
Victor Valley College
Allied Health Building # 32
ATTN: CNA APPLICATION
18422 Bear Valley Road
Victorville, CA 92395
A complete application consists of the following:
 Unofficial Transcripts of all colleges from which entry requirements were met or Assessment test
results if using to meet the entry requirements.
 If Assessment tests were taken, applicant must provide a copy of the results.
 A completed & signed “Conviction/No Conviction” section of the application, with CDPH clearance
documentation if needed.*
 A completed, and signed, application for the Summer 2016 Certified Nursing Assistant Course.
 Submit all forms in their entirety, completed and signed, to the Allied Health Office between
8:30 AM, April 4th, 2016 and 5:00 PM, April 22nd, 2016.
 All notifications will be communicated thru a valid email address.
Microsoft based emails are not recommended due to VVC emails being blocked by Microsoft. (i.e. hotmail, live, or msn)
Please note: If any item is missing, the application packet will not be accepted. Students will receive notification of application status by
email. Notification occurs approximately 3 weeks after the submission deadline. No telephone verification is provided by the Allied Health
department.
Admission into the Certified Nursing Assistant course is contingent upon a clear background check, drug screening and health screening. It
is imperative that applicants review the “Disqualifying Penal Code Sections” prior to submitting an application. Applicants who have been
convicted of any of the listed violations may be ineligible for certification as they may not receive the required criminal background clearance
for participation in this program and subsequent employment in long term care environment. Certification of applicants with convictions listed
may be reconsidered by ATCS (Aide and Technician Certification Section of the State of California) only if misdemeanor actions have been
dismissed by a court of law or a Certificate of Rehabilitations has been obtained for felony convictions. Any other convictions other than minor
traffic violations must be reviewed by ATCS.
Students must meet regulatory requirements for class attendance, health clearance, background check clearance, have a valid
social security number and an American Heart Association Healthcare Provider CPR card to participate in the course. Upon
successful completion, students will be eligible to take the State of California Certification Examination to become a Nursing
Assistant qualified for employment in an acute or long-term health care facility. Separate testing and certification fees are
required.
*Please be aware, if you have been convicted of a crime you must provide documents indicating clearance from the California
Department of Public Health, Nurse Assistant Section (CDPH) when you submit your application to Victor Valley College. For
information on how to clean up your criminal record please visit www.courts.ca.gov.
SU16 CNA Application.docx
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VICTOR VALLEY COLLEGE
CERTIFIED NURSING ASSISTANT COURSE
SUMMER 2016 APPLICATION
In order to be considered for admission to the Certified Nursing Assistant Course, students must submit this completed form.
*All Fields Required/Please Print Clearly
Name:
____________________________________________________________________________________
Last
First
List maiden name and other names used:
Middle
_________________________________________________________
VVC Student I.D. Number: ________________________
Contact Information:
____________________________________________________________________________________
Number & Street
City
State
Zip Code
____________________________________________________________________________________
Home Telephone
Cell Number
E‐Mail Address ____________________________________________________________________________________________
Microsoft based emails are not recommended due to VVC emails being blocked by Microsoft. (i.e. hotmail, live, or msn)
Social Security Number: _______‐ _____‐_______
Date of Birth: ___________/________/____________
The State of California requires that all persons preparing to be a CNA, prior to registering, acknowledge whether or
not they have been convicted by any court of a crime other that a minor traffic violation.
Have you ever been convicted by any court of any crime, other than a minor traffic violation?
*Yes____________
No_____________
*Please be aware, if you answered *Yes to this question, you must supply the following information to the California Department of Public
Health, Nurse Assistant Section when you send in your application to take the certification exam:
•
Dates and nature of the incident(s)
•
Letters from probation officer (if applicable).
•
Disposition of the case (Provide court papers)
•
Letters of recommendation (if available).
•
Current status
I certify that all information contained on this form is true and accurate. I understand that failure to disclose or falsify any documents will automatically
and permanently disqualify my application and admission into the Certified Nursing Assistant Program.
Applicant’s Signature
Date
SU16 CNA Application.docx
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VICTOR VALLEY COLLEGE
CERTIFIED NURSING ASSISTANT COURSE
SUMMER 2016 APPLICATION
Entry Requirement/Course Work Verification
ATTENTION: Entry requirements must be completed, with a grade posted to applicable transcript at the
time application is submitted. A copy of these unofficial transcripts must be submitted with application.
If using an Assessment to meet the entry requirements, a copy of the assessment results must be
submitted at time of application.
Entry Requirements:

Completion of English 6 with grades of “C” or better or placement in a higher course by
approved score on Accuplacer assessment test, i.e. English 50
OR

Completion of ESL 43 and ESL 47 with grades of “C” or better or placement in a higher
course by CELSA matriculation assessment process
Please fill in required fields:
Entry Requirements
OR Assessment Test
College where course
was completed
Grade OR
Assessment Score
SU16 CNA Application.docx
Date Completed
(Semester/Year)
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VICTOR VALLEY COLLEGE
CERTIFIED ASSISTANT NURSING COURSE
SUMMER 2016 APPLICATION
Statistical Information
The following information is requested for compliance with Section 56110, Title V California Administrative Code
reporting procedure and will be used for statistical purposes only.
Primary Race or Ethnic Group:
American Indian/Alaskan Native
Other Asian/Pacific Islander
Asian Indian
Native Hawaiian/Other non-Filipino Pacific Islander
White/Caucasian
Hispanic/Latino
Filipino
Mixed Race
___
Age: ____
Sex:
Male
Female
Primary language spoken at home:
English
Other
If Other, please state: _____________________________
Are you a U.S. Veteran or widow/widower of a U.S. veteran?
High School attended: ________________________________________
Graduated?
GED?
Date of Completion: ____________________
(month/year)
Did you participate in any ROP (Regional Occupational Program) Programs?
If yes, please list ROP Programs attended:
_______________________________________________Completed?
Program Name
_______________________________________________Completed?
Program Name
If yes, what year? __________
Location
_______________________________________________Completed?
Program Name
If yes, what year? __________
Location
_______________________________________________Completed?
Program Name
If yes, what year? __________
Location
If yes, what year? __________
Location
SU16 CNA Application.docx
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