Home Health AIDE Training Program Application for Enrollment Question Title * 1. Last Name (Required.) Question Title * 2. First Name (Required.) Question Title * 3. Middle Initial Question Title * 4. Address (Required.) Question Title * 5. Apt# Question Title * 6. City (Required.) Question Title * 7. State (Required.) Question Title * 8. Zip Code (Required.) Question Title * 9. Telephone # (Required.) Question Title * 10. Email Address (Required.) Question Title * 11. Are you at least 18 years old (Required.) Yes No Question Title * 12. Can you show proof of legal authorization to work in the U.S. (Required.) Yes No Question Title * 13. Do you have a High School Diploma or GED? (Required.) Yes No Question Title * 14. If yes, please enter the name of the High School or GED program you received your diploma from: Question Title * 15. Can you commit to a 40 hour per week training for three weeks? (Required.) Yes No Question Title * 16. Please read carefully and sign : I certify that this application was completed by me and the entries contained are true and complete. I understand any false statements made on this application or misrepresentation or omission of facts requested on this application are grounds for rejection of this application or dismissal from the Hebrew Home at Riverdale Training Program.Enter Full Name (Required.) Question Title * 17. Enter completion Date (Required.) Date / Time Date Done
