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TSNA CNA Program Application Screening Form

Thank you for your interest in The Stephanie Nursing Academy!

We are proud to offer a comprehensive CNA training program rooted in compassion and excellence. This screening form helps us learn more about you before scheduling an interview. Please complete all fields honestly. You must be at least 16 years old to apply.

Basic Information

First Name *

Last Name *

Date of birth *

Email *

Phone *

Are you currently employed or in school? *

Yes

CNA Program Fit

Why do you want to become a CNA? *

Are you a minor (under 18 years old)? *

Yes

Note: “Minors must be at least 16 years old to enroll.”

Parent/Guardian Full Name

Parent/Guardian Phone Number

Parent/Guardian Email

Do you have any criminal background? *

Yes

Please provide details of your criminal background

Can you commit to at least 12–14 weeks of weekend CNA training? *

Yes

Note: “Length may vary depending on holidays.”

Are you able to attend mandatory clinicals that may be outside of the Antelope Valley? *

Yes

Do you have reliable transportation to attend class and clinicals? *

Yes

Do you have a strong support system to help you succeed during this program? *

Yes

Tell us a little about your support system. Who are they, and how do they support you?

Referral Info

How did you hear about us? *

Instagram

Facebook

Tiktok

Google

Referral

Other

Referral/Other

Final Reflection

What does being compassionate mean to you? *

Program Interest

Which program are you interested in? *

Weekend Program

Day Program

Commitment Confirmation

Social Media

Do you have a Facebook account? *

Yes

facebook account

Do you have an Instagram account? *

Yes

instagram account

Do you have a TikTok account? *

Yes

tiktok account

DISCLAIMER:

This pre-application form does NOT guarantee you a spot in the class. After submission, a faculty member will review your information. If selected, you will be contacted within 24–48 hours to schedule an interview as the next step.

Location

2231 E. PALMDALE BLVD STE N

PALMDALE, CA 93550

COUNTY OF LOS ANGELES

Contact

(877) 876-2513