Student Intake Form
Page 1
Thank you for enrolling in a class or program with the 1199 New England Training Fund. To be eligible for these classes or programs you must have completed your probation period at a Connecticut nursing home that contributes to the Training Fund
Personal Information
First Name
Last Name
Social Security #
Home Mailing Address
City
State
Please select...
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
DC
PR
Zip Code
Cell Phone
Home Phone
Email
Race/Ethnicity
Please select...
African
Asian
Black/African American
Caucasian
Hispanic/Latino
Middle Eastern
Native American
West Indian
Other Race/Ethnicity
Gender
Please select...
Female
Male
Date of Birth
Are you a parent/guardian?
Please select...
Yes
No
Number of Children
Please select...
1
2
3
4
5
6
7
8
9
10
11
12
List ages of children under 18 (comma separated)
For assistance regarding this form, contact Angela Alfieri,
AAlfieri@1199trainingfund.org
Page 2
Nursing Home Information
Nursing Home Name
Please select...
60 West
60 West HSG
Advanced Nursing & Rehabilitation of New Haven
Amberwoods
Arden House
Arden House HSG
Autumn of Bucks Hill
Autumn of Bucks Hill HSG
Autumn of Cromwell
Autumn of Cromwell HSG
Autumn of New Britain
Autumn of New Britain HSG
Autumn of Norwalk
Avery Heights
Avery Heights HSG
Bloomfield Health Care
Cassena Care of Stamford
Cassena Care of Stamford HSG
Cassena of Norwalk
Cassena of Norwalk HSG
Chelsea Place
Complete Care Glendale
Complete Care Harrington
Complete Care Meriden
Davis Place
Fox Hill Center
Fresh River Care Center
Fresh River HSG
Glen Hill Center
Governor's House
Governor's House HSG
Hebrew Center
Hebrew Hospital
Kimberly Hall North
Kimberly Hall North HSG
Kimberly Hall South
Kimberly Hall South HSG
Long Ridge Post Acute Care
Madison House
Madison House HSG
Maple View Manor
New Haven Center
Newington Rapid Recovery
Orange Health Care Center
Park Place Health Center
Park Place Health Center HSG
Saint John Paul II Center
Saint Mary Home
Salmon Brook
Silver Springs Care Center
Silver Springs Care Center HSG
Southport Center
St. Camillus
St. Camillus HSG
St. Joseph's Center
St. Joseph's Center HSG
The Reservoir
Torrington Center
Touchpoints at Bloomfield
Touchpoints at Chestnut
Touchpoints at Farmington
Touchpoints at Farmington HSG
Touchpoints at Manchester
Touchpoints at Manchester HSG
Trinity Hill Care Center
Villa at Stamford
Waterbury Center
Waterbury Gardens
West Hartford Health & Rehab
West Hartford Health & Rehab HSG
West Haven Center
West River Rehabilitation
Western Rehabilitation
Westport Rehabilitation
Westside Care Center
Westside Care Center HSG
Job Title
Please select...
CNA
Dietary
Housekeeping
LPN
Maintenance
Recreation
RN
Other
Shift
Please select...
1st
2nd
3rd
Per Diem - Varies
Date of Hire
Training Information
Course Information
Please select...
High School Diploma
LPN Prep
College Prep English and Math
Pre-Science Prep
Typing
Test Taking Skills
Study Skills
Research Writing
Medical Terminology
Tutoring
TEAS Test Preparation
Creative Writing Workshop
Subject to receive tutoring
Please select...
English
Math
Chemistry
Biology
Anatomy and Physiology
Sociology
Psychology
TEAS Test Preparation
Other
Other subject
Semester Enrolling For
Please select...
Adult Education Spring 2022 A (January -May)
Adult Education Spring 2022 B (January - March)
Adult Education Spring 2022 C (April - June)
Adult Education Summer 2022 (May-August)
Adult Education Fall 2022 (Sept.-Dec.)
Adult Education Winter 2022
Do you have a high school diploma?
Please select...
Yes
No
Last Grade Completed
Which of the following devices do you have access to at home?
Please select...
Personal Computer (PC)
Laptop
Tablet
Smart Phone
Do you have a reliable internet service which will allow you to do online courses or training?
Please select...
Yes, it's very fast
Yes, but it's kind of slow sometimes
No
How often do you use a computer?
Please select...
Daily
A few times per week
Once in awhile
What do you use a computer for?
Please select...
School
Email
Searching for information on the internet
Paying bills/other business
For assistance regarding this form, contact Angela Alfieri,
AAlfieri@1199trainingfund.org