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Personal Information

Name
Address
Training Program
The facility can Not be banned from having students train in the facility. Please have the facility complete the Affiliated Clinical Contract and email it to Admin@IndianaNursingAcademy.com Forms are found on the web page of the program you"re interested in.
Have you been convicted of a felony? Limited State Background Check is Required by the ISDH.

Next Two Questions are for the QMA Program ONLY

QMA ONLY: Have you worked 1,000 hours as a CNA in the past 24-Months?
State Requirements State You Must Have Worked as a CNA 1,000 Hours in the Past 24-Months from the First Day of Class. The 1,000 Hours Can Be from Multiple Employers.
QMA ONLY: Do you have a High School Diploma or GED?
Proof of Diploma or GED is Required to Sit for the QMA State Exam.

Health Related Information

Do you have any allergies, such as Latex gloves.
Have you had a Physical completed in the past 12-Months?
Have you had a TB Test in the past 12-Months?
TB Test and Physical dated within the past 12-months are Required. You can use a physical and/or TB Results from a past employer as long as it"s dated from the last 12-months of the First Day of Class.
Name of Vaccine and Date(s). This is Required for Any Student Who will be Completing Clinicals with Our Clinical Site in Avon. If You will be Choosing a Different Facility to Complete Clinicals with, it"s Important to Learn First if the Vaccine is Required at That Facility.
Click or drag a file to this area to upload.
Upload Proof of High School Diploma/GED (QMA Only), TB, Physical, Covid-19 Vaccines Here or Email Files to Admin@IndianaNursingAcademy.com

Emergency Contact Information

Name
Your spot in the program is Only held once a deposit has been made.
Return to the program page and complete a Deposit with the "REGISTER NOW" tab to Secure Your Spot.

Consent to Utilize and Release Information as Needed for Program Clinicals and State Purposes

Signing this form grants Indiana Nursing Academy permission to use and share the provided information where Indiana Nursing Academy deems necessary, including but not limited to meeting requirements of the training program and affiliated clinical sites. Indiana Nursing Academy will Not use the provided information to Discriminate, such as against race, color, religion, sex (including pregnancy, sexual orientation, or gender identity), national origin, disability, age or genetic information. Completing this form does Not guarantee or promise anything, including the acceptance into a program offered by Indiana Nursing Academy. Only a deposit reserves a seat in a program.