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Certified Home Health Aide (CHHA) Class Interest Form
1.
Do you have a valid, unexpired driver’s license?
Yes
No
2.
Do you have your own vehicle with
current
insurance and registration?
Yes
No
3.
Have you ever been arrested (including jail, prison, or detention), whether convicted or not?
Please note: This question must be answered honestly, as any history may delay the approval of your certification application.
Yes
No
4.
Do you have at least one year of experience as a caregiver?
(This may include providing care for a family member.)
Yes
No
5.
Please provide your First and Last Name
6.
Please provide your best contact number
7.
Please provide your email address
8.
Do you give Senior Helpers permission to contact you by phone, text and/or email regarding upcoming Certified Home Health Aide classes, employment opportunities or related services?
Yes, I give permission.
No, I do not give permission.
Thank you for your interest in our CHHA class with Senior Helpers. We will review your responses and contact you with next steps. Please ensure your contact information is correct so we can reach you promptly
9.
Are you a Certified Nurse Aide CNA with the State of New Jersey, with a current, valid license?
Yes
No