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Phone Number: +1 773 506 1503

Email: info@cclctraining.org

Notice to Students

Do not sign this agreement before you have read it or if it contains any blank spaces.
This agreement is a legally binding instrument and is only binding when the agreement is accepted, signed, and dated by the authorized official of the school or the admissions officer at the school's principal place of business. Read all pages of this contract before signing.
You are entitled to an exact copy of the agreement and any disclosure pages you sign.
This agreement and the school catalog constitute the entire agreement between the student and the school.
Any changes in this agreement must be made in writing and shall not be binding on either the student or Chicago Community Learning Center unless such changes have been approved in writing by the authorized official of the school and by the student or the student's parent or guardian. All terms and conditions of the agreement are not subject to amendment or modification by oral agreement.
The school does not guarantee the transferability of credits to another school, college, or university. Credits or coursework are not likely to transfer; any decision on the comparability, appropriateness and applicability of credit and whether credit should be accepted is the decision of the receiving institution.

Student's Right to Cancel

The student has the right to cancel the initial enrollment agreement until midnight of the 15 business day after the student has been admitted. If the right to cancel is not given to any prospective student at the time the agreement is signed, then the student has the right to cancel the agreement at any time and receive a refund on all the monies paid to date within 10 days of cancellation. Cancellation should be submitted to the authorized official of the school in writing.

Enrollment Agreement

Form 1/7

First Name *

Last Name:

Address *

City *

State *

ZIP Code *

Telephone #:

Phone Number: Home

Phone Number: Cell *

Phone Number: Work

Email Address *

Last Four Digits of SSN *

PROGRAM INFORMATION

Date of Admission *

Course Name *

Program Start Date *

Scheduled End Date:

Enrollment Type *

Full-Time

Part-Time

Class Schedule *

Day

Evening

Days/Evenings Class Meets:

Mon

Tue

Wed

Thu

Fri

Sat

Sun

Time Class Begins:

Time Class Ends:

Number of Weeks:

Total Clock Hours:

FINANCIAL AID & TUITION

Chicago Community Learning DOES NOT offer Title IV Financial Aide at this time.

I agree to the tuition fees

I agree to the refund and cancellation policy

Tuition Cost:

$5000

Books and supplies:

$960

Tests:

$550

Other expenses:

$1490

Total Cost for Program / Course:

$8000

STUDENT ACKNOWLEDGMENTS

I hereby acknowledge receipt of the school's catalog, which contains information describing programs offered, and equipment or supplies provided. The school catalog is included as part of this enrollment agreement, and I acknowledge that I have received a copy of this catalog.

I have carefully read and received an exact copy of this enrollment agreement.

I understand that the school may terminate my enrollment if I fail to comply with attendance, academic, and financial requirements or if I fail to abide by established standards of conduct, as outlined in the school catalog. While enrolled in the school, I understand that I must maintain satisfactory academic progress as described in the school catalog and that my financial obligation to the school must be paid in full before a certificate or credential may be awarded.

I hereby acknowledge that the school has made available to me all required disclosure information listed under the Consumer Information section of this Enrollment Agreement.

I understand that Chicago Community Leaming Center does not guarantee transferability of credit and that in most cases, credits are not likely to transfer to another institution. In cases where transferability is guaranteed, Chicago Community Learning Center must provide me copies of transfer agreements that name the exact institution(s) and include agreement details and limitations.

I understand that the school does not guarantee job placement to graduates upon program completion.

I understand that complaints, which cannot be resolved by direct negotiation with the school in accordance to its written grievance policy, may be filed with the Illinois Board of Higher Education, 1 N. Old State Capitol Plaza, Suite 333, Springfield, IL 62701 or at www.ibhe.org.

Medical Evaluation / Physical Examination Form

Form 2/7

Check the box for the appropriate nursing/allied health program

Nursing Assistant

ADDITIONAL STUDENT INFORMATION

Birth date *

Gender *

Male

Female

Others

Health History

Rate your current health status *

Excellent

Good

Fair

Poor

Allergies:

Medications? *

Yes - List medication and reaction:

Latex allergy? *

Yes

Food allergy? *

Yes - List food(s)/reaction:

Are you pregnant? *

Yes

Due Date: (if pregnant) Are you seeing an OB/GYN:

Yes

Do you have any lifting, pushing, pulling, bending, or twisting restrictions *

Yes – Please explain:

ESSENTIAL TECHNICAL STANDARDS

The attendance requirements and stamina demand require the Nursing Assistant and Allied Health students to be in good physical and mental health. In the interest of the student's personal safety and the safety of patients and clients, and other healthcare workers, students must meet, with or without reasonable accommodation, the Essential Technical Standards before admission into the program is finalized. Students are required to complete a self-assessment of their capability to meet these standards. Please read the Essential Technical Standards carefully, and initial each technical standard, only if you can comply with the standard. Students must present a completed copy of the Essential Technical Standards to their Healthcare Provider for review at the time of their physical examination. When complete, please sign, date and upload it into your Electronic Profile. If a student cannot meet one or more of the standards, they must meet with the Director of the Program for which they have applied to discuss reasonable accommodations.

Do you have any conditions that would interfere with your ability to perform the Essential Technical Standards? *

Yes - If yes, please explain:

Please check the box next to each standard if you can comply.

Mobility: Physical ability, flexibility, strength, and stamina (e.g., standing, walking, bending, lifting 35lbs, assisting patients).

Motor Skills: Coordination and dexterity sufficient to perform patient care (e.g., manipulate medical equipment, keyboards).

Visual: Visual skills, depth perception, color identification necessary to perform assessments, read expressions, interpret written words.

Hearing: Ability to hear and interpret environmental noises, verbal orders, alarms, cries for help.

Tactile: Ability to sense heat, cold, pain, pressure.

Communication: Use English effectively (speech, reading, writing), demonstrate sensitive interactions, accurately convey medical info.

Acquire Knowledge: Ability to possess clinical inquiry, seek resources, develop solutions beyond memorization.

Clinical Judgment: Ability to critically think, solve problems, make decisions, interpret assessments, develop care plans.

Professional Attitude: Demonstrate concern, integrity, ethical conduct, emotional and mental stability, function effectively under stress.

I acknowledged that:

The information provided is true and correct to the best of my knowledge. I am aware that ANY change in my physical or mental health status, including pregnancy and/or medication use must be immediately reported to the Director of the Nursing or Allied Health Program to which I am assigned. Chicago Community Learning Center has my permission to release these test results to the clinical education agencies to which I am assigned. My Healthcare Provider may release health related information to the Director of the Program in which I am enrolled.

Student ID Form

Form 3/7

My student ID is my responsibility to have on and visible during class and during clinical.

If lost there will be a $5.00 fee for a replacement ID.

I agree and will be responsible to the terms of having a student ID.

Uniform Size Form

Form 4/7

Please select your uniform size based on the chart below. Note: Top and Pants must be the same size. Uniform comes in a set and cannot be separated.

Unisex Scrub Set Size Chart:

Size	XXS	XSM	SML	MED	LGE	XLG	2XL	3XL	4XL	5XL	6XL
Chest	28-30	31-33	34-36	37-39	40-42	43-45	46-48	49-51	52-54	55-57	58-60
Waist	28-30	31-33	34-36	37-39	40-42	43-45	46-48	49-51	52-54	55-57	58-60
Hip	28-30	31-33	34-36	37-39	40-42	43-45	46-48	49-51	52-54	55-57	58-60
Center Back Length	25	25.5	26.5	27.5	28.5	29.5	30.5	31.5	32.5	33.5	34.5

Select your Uniform Size *

SIZE TIP: If you're a guy ordering unisex fits scrubs, they should ideally be true to size. For the ladies, consider ordering one size smaller than you would in a women's fit scrub top or pants.

Consent to Test and Release Information

Form 5/7

I grant the Chicago Community Learning Center, Chicago Campus Permission to:

Administer, score, and interpret assessment test of interest, and abilities related to my employment, training, and services needed.
Use the results of the test given to me to make decisions about training programs, referrals, and other related services.
Obtain information from and/or release information to any of the following:
- Agencies
- Employers
- School/Colleges
- Institutions/Business UI Wages
- Transmit file to TARA

This information may be used to assist my eligibility determination, my progress in WIA funded activities, and /or provided verification of employment.

I have read and fully understand the above information. Further, I also understand that attendance at the initial assessment does not guarantee participation in WIA.

Background Check Form

Form 6/7

Health Care Worker Background Check

Authorization and Disclosure for Criminal History Records Information (CHRI) Check

I hereby authorize the Illinois Department of Public Health (the Department), the Department's designees, educational entities that train and/or test health care workers, staffing agencies, my current or potential employer, or a health care facility where I want to volunteer to initiate/request a CHRI check on me. I further authorize the Illinois State Police (ISP) and/or the Federal Bureau of Investigation (FBI) to release information and photographs relative to the existence or nonexistence of any criminal record, which it might have concerning me, to any initiator/requestor solely to determine my suitability for training or testing in a health care training program, employment, continued employment, or to work as a volunteer. I further authorize any entity that maintains criminal records and photographs relating to me, including but not limited to a local unit of government in any State, to release those records and photographs to the ISP, FBI, or the Department. I authorize the Department to provide any health care facility, training program or staffing agency, to which I have provided this authorization and disclosure form, a copy of my ISP CHRI and a determination of eligibility of the FBI CHRI. I certify that the ISP, FBI, any entity that maintains criminal records and photographs, the Department, and any of their employees or officers who furnish this information shall be held harmless from all liability, which may be incurred as a result of releasing such information. I further acknowledge that a educational entity or a health care employer shall not be liable for the failure to hire or retain me as an applicant, student, employee, or volunteer if I have been convicted of committing or attempting to commit one or more of the offenses stated in the Health Care Worker Background Check Act (225 ILCS 46/25).

I understand that any false statements or deliberate omissions on this document may be grounds for disqualification from employment, training, or volunteering, if discovered after employment, training, or volunteering begins, and can result in discipline up to and including my termination of employment, being a volunteer, or a student.

I understand that the information requested below regarding gender, race, height, eye color, hair color, weight, place of birth and date of birth is for the sole purpose of identification and the accurate gathering of the criminal history record information, and that it will not be used to discriminate against me in violation of the law. I understand that the provision of my Social Security number is required by law. A facsimile or photographic copy of this authorization will be as valid as the original.

First Name *

Middle Name (if any)

Last Name *

Mailing Address *

City *

State *

Zip Code *

Other Names Used

Telephone

States Where You Have Lived? *

Race *

Height *

ft in

Weight *

lbs

Date of Birth *

Social Security Number *

Hair Color *

Eye Color *

Place of Birth *

Have you ever had an administrative finding of Abuse, Neglect or Theft? *

Yes

Have you ever been convicted of a criminal offense other than a minor traffic violation (do not include convictions that have been expunged, sealed or adjudicated delinquent)? *

Yes

I certify that the above is true and correct and give my consent for my name to appear on Department's Health Care Worker Registry with the results of my criminal history records check.

As the parent or guardian of the above named individual, who is younger than the age of 17, I give my consent for this named individual to have a criminal history records check.

Signature of Parent or Guardian (if applicable)

Date

Note: Make sure the data you entered matches the data on your ID

Media Release Form

Form 7/8

I, , grant permission to Chicago Community Learning Center, hereinafter known as the "Media" to use my image (photographs and/or video) for use in Media publications including:

(Check All That Apply) *

Videos

Email Blasts

Recruiting Brochures

Newsletters

Magazines

General Publications

Website and/or Affiliates

Other:

I hereby waive any right to inspect or approve the finished photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the image.

Please select the paragraph below which is applicable to your present situation: *

I am 20 years of age or older and I am competent to contract in my own name. I have read this release before signing below, and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.

I am the parent or legal guardian of the named child. I have read this release before signing below, and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.

Student Acknowledgement Form

Form 8/8

The Applicant Understands:

Chicago Community Learning Center is an Illinois Board of Higher Education (IBHE) Licensed facility as a Private Vocational School in Health-Career Education; we do not accept credit from previous education entities or any experimental learning, or CLEP.
Chicago Community Learning Center only assists with Job Placement in the Field of health-care study, but we DO NOT guarantee job placement.
Chicago Community Learning Center reserves the right to discontinue training for unsatisfactory progress, non-payment of fees or failure to abide by school guidelines.
Chicago Community Learning Center reserves the right to reschedule the training start date when the number of participants scheduled is too small.
Under WIOA tuition ITA, Chicago Community Learning Center only pays for License exams once for C.N.A State License, Patient Care Technician License with EKG & Phlebotomy. Retakes of any license exam is the responsibility of the student.

I have carefully read and received an exact copy of the acknowledgement.

I understand that Chicago Community Learning Center may terminate my Contract agreement if I fail to comply with attendance and financial requirement or if I disrupt the normal activities of training. I understand that my financial obligation to Chicago Community Learning Center must be paid in full before a certification may be awarded.

Student Signature:

Date: