Individual Registration

The student must be the one filling out this application. Please have all documents ready to upload before starting the application.

CNA Certification (Utah Nursing Assistant Registry)
Current CPR Certification
Practical Training Instructor Letter (A sample letter can be found here.)

Ticket Information

Ticket Type	Price	Quantity
Member registration	$750.00
Non-member registration	$1,100.00

Organization/Facility *

First Name *

Last Name *

Billing Address *

Address 2

City *

State *

Zip *

Please select if you will attend in person or virtual (If you are in the SLC valley, please choose in person. Virtual attendees will be approved on a case-by-case basis.) *

In-Person

Virtual

Phone *

Job Title *

Email *

Do you have a high school diploma? *

Yes

If no, have you successfully passed the General Education Development (GED) test?

Yes

Do you have a current certification as a nursing aide, in good standing, from the Utah Nursing Assistant Registry? *

Yes

Please upload a copy of your CNA certification. *

Do you have at least 2,000 hours experience within the two years prior to application working as a certified nurse aide in an approved health care setting? *

Yes

Do you have a current cardiopulmonary resuscitation (CPR) certification? *

Yes

Please upload a copy of your CPR Certification. *

Each student will choose an On-Site Practical Training Experience Instructor. Please acknowledge that your On-Site Practical Training Experience Instructor meets the qualifications explained in the event description *

Yes

On-Site Practical Training Experience Instructor First Name *

On-Site Practical Training Experience Instructor Last Name *

On-Site Practical Training Experience Instructors nursing license number *

On-Site Practical Training Experience Instructor Phone Number *

On-Site Practical Training Experience Instructor Email *

Please upload a signed letter of acknowledgement from the chosen On-Site Practical Training Experience Instructor detailing they meet all the requirements. (A template of this letter can be found in the event registration description.) *

I am the applicant described and identified in this application for licensure, certification or registration in the State of Utah. *

Yes

I am qualified in all respects for the license, certificate, or registration for which I am applying in this application. *

Yes

To the best of my knowledge, the information contained in the application and its supporting document(s) is free of fraud, misrepresentation, or omission of material fact. *

Yes

Please type your name for an electronic signature. *

Payment Information

Coupon

Amount

Discount Amount

Gross Amount

Payment Method *

Credit Card via Authorize.net Mail Check

Credit Card Number*

Expiration Date*

Card (CVV) Code*

Card Holder Name*

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