Nursing Home Administration Program Application Form

Wisconsin regulation NHA Chapter 1 was consulted to create this application process. All applications will be reviewed by instructor and, if necessary, NHA board educational liaison, to duly consider appropriate alternative qualifications, such as extensive work experience in the industry.

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* 1. Personal Information

First Name

Last Name

Street Address

City

State

Phone number

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* 2. Confirm email address

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* 3. High School Education

Name of School

City and State

Year of Graduation

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* 4. College/University Name (Post-Secondary Education)

Institution Name

City and State

Year of Graduation

Degree and Major

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* 5. Graduate Degree: College/University

Name of Institution

City and State

Year of Graduation

Degree and Major

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* 6. Experience in Healthcare Administration

Job Title

Dates (MM/YY) to (MM/YY)

Employer Name

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* 7. Responsibilities (Healthcare Admin Experience)

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* 8. Experience in Healthcare (non-admin)

Job Title

Dates (MM/YY) to (MM/YY)

Employer Name

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* 9. Responsibilities (Healthcare Non-Admin)

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* 10. Have you started or completed a practicum yet?

Started

Completed

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* 11. If you have started or completed your internship/practicum:

Institution Name

City, State

Supervisor Name

Supervisor Contact Information

Practicum Hours Completed

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* 12. Description of Internship/Practicum Duties

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* 13. I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that any false statements or omissions may result in the rejection of my application or dismissal from the program (type your full name in the box below).