Aloha! Please find program information below and fill out the registration form for consideration in our Certified Nursing Aide (CNA) training program. Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *EmailConfirm EmailPlease use email you check, as this will be the initial form of communication.Mobile or Other Primary Phone *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeIslandIslandO'ahuMauiKaua'iHawai'i IslandOther/NoneGender *GenderMaleFemaleDecline to answerDate of Birth *Race (check all that apply) *American IndianBlack or African AmericanWhiteHispanic/LatinoNative Hawaiian or Part HawaiianOther Pacific IslanderFilipinoChineseJapaneseKoreanVietnameseOther AsianAre you a BSH employee? *YesNoAre you a US citizen? *YesNoAre you a Veteran? *YesNoAre you a permanent resident (Green Card holder)? *YesNoAre you receiving government benefits? *YesNoCurrent Gov. BenefitsEducationEducation Level *Highest Level of schooling completedLess than High SchoolHigh School or EquivalentAssociate's DegreeBachelor's DegreeMaster's DegreeApprenticeshipArea of degree or apprenticeshipAre you currently attending or have previously attended a UH campus? *YesNoEmploymentEmployment Status *Current employment statusUnemployedEmployedEmployed but received letter of terminationUnderemployed (less than full-time)Have you recently lost your job or hours? *YesNoWhat are the details of your lost job/hours? *Current employment statusBeen laid offLost hours with my employerLost hours or wages from self-employmentBeen furloughedName of EmployerPosition/Job TitleStarting Salary(Estimated hourly rate or annual salary)Ending Salary(Estimated hourly rate or annual salary)Healthcare Provider *select oneAlohaCareHMSAHMAAKaiser PermanenteUnited Healthcare'Ohana Health PlanPSWAOtherNo CoverageOther HealthplanCoverage UntilAre you employed in your field of study?YesNoAdditional InformationWere you referred to BSH? *YesNoIf yes, how?Mailed advertisementMailed advertisementFriend/RelativeBSH/Hariett/Local5 StaffEmployerCommunity AgencySocial MediaPosted FlyerOtherWhat program(s) are you interested in? *Certified Nursing Aide (CNA)Why do you want to take this training *Obtain employmentCareer advancementChange of careerContinuing educationWage increaseOtherType of employment seeking (check all that apply): *Full-timePart-timeTemporaryShift WorkContractDo you have (check all that apply):High-speed/Broadband InternetDesktop or laptop computerSmartphoneHeadsetWhat are your training goals; what do you hope to learn? *What are your career goals?Do you require any support services:Childcare SubsidyTransportation Subsidy (Bus Pass)By submitting this application, I certify that the above statements are true to the best of my knowledge. I give my consent to Banquet Solutions Hawaii Inc. to provide my application information to another appropriate agency or partner for support services. *AgreeSubmit
