Ottawa County STNA Program | BAC | Ottawa County, Ohio

Student Information

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone *

Email *

You will receive a copy of your application.

Age *

Birth Date *

Graduation Year *

Parent/Guardian Name *

First

Last

Parent/Guardian Cell Phone *

Parent/Guardian Email *

Your parent/guardian will receive a copy of your application.

School Information

Name of School *

School Counselor/Career Readiness Coordinator *

First

Last

School Counselor/Career Readiness Coordinator Email *

Your School Counselor/Career Readiness Coordinator will receive a copy of your application.

Student Questions

From the list below, check the careers your most interested in: *

STNA (nursing homes, assisted living facilities)
STNA (hospice care)
Home Health Aide (in-home care)
Patient Care Assistant (hospitals, outpatient facilities)
Clinical Assistant (hospitals, physicians' offices, outpatient facilities)

What makes you a quality candidate for this program? Please check all that apply: *

What special skills or background knowledge do you have that will help you be successful in this program? Please check all that apply: *

Took anatomy/physiology classes in high school
Have some knowledge of medical tools & equipment
Have CPR Training/Certification

Name one strength and one weakness you have as a student: *

Do you have any concerns about committing to this program? Do you think you would need any special accommodations? *

Are you available Tuesdays, Wednesdays and Thursdays from 11:30am-2:30pm during the school year? *

Yes
No

Do you hold a Driver's License? *

Yes
No

Transportation *

Please explain your transportation arrangements, regardless if you have a license or not. Please be specific. (e.g. parents/guardians drop off/pickup, drive your own car, take transit bus, other relatives):

Are you currently employed? *

Yes
No

If you answered YES, who is your employer? *

If you answered NO, would you be interested in an internship and/or employment with a local employer? If yes, please explain. *

Acknowledgement

By signing below, we (student and parent/guardian) acknowledge the following:

"We have been made aware of the details of this program. We understand that this application does not necessarily mean that the student will be accepted into the program. We understand that the student would be subject to all high school rules and school board policies throughout this program. We understand and agree that the student’s participation in this program may be terminated at any time for any reason, and that in this case, the student would be required to report back to their high school."

Student Signature *

Date *

Parent Signature *

Date *

Email Confirmation

Once you submit the completed form, you will receive an email confirmation along with a copy of your application (be sure to check your junk/spam folder).

Please email aspangler@ocic.biz with questions.