Northern California Nursing Academy

Name of Organization:

California Secretary of State File Number: (If applicable)

Address:

Service(s) Offered:

Website URL:

How many years has your organization been in business?

How many employees do you currently have?

Name of Contact Person:

Title / Position:

Contact Number:

Email Address:

Which training course/s would you like us to provide? (You can select multiple program):

HIPAA Infection Control Dementia Body Mechanics Nutrition Restorative Care ESL Other

Would you be interested in becoming a clinical training partner?

Yes No

* We will be sending you additional documents to establish your organization as a clinical site.

Which program(s) you are willing to provide clinical practices and experience with our students? (You can select multiple program):

Advanced Caregiver Program Nurse Assistant Home Health Aide Vocational Nursing

Would you like to recruit our students and graduates for your organization?

Yes No

What are your current job openings?

Caregivers CNA - Certified Nurse Assistant HHA - Home Health Aide RNA - Restorative Nurse Assistant

What is your typical hourly pay range? (select all that apply)

$16 - $18 $19 - $21 $22 - $24 $25 +

Organization Interest Form