By signing this application you are granting Stepping Stones Educational System, Inc., permission to contact your physician if we need to confirm any
information you have given us regarding any medical limitations that could affect your ability to successfully meet the objectives of our program. You are
also stating that all the information given in this application is true and correct. If you have disclosed or answered any questions untruthfully you
understand it could result in you being immediately dismissed. All information you release to us on this application will be kept confidential and only
used for the purposes of confirming information for admission to our program including but not limited to a Criminal Background History.
Educational Institution Name:
STEPPING STONES EDUCATIONAL SYSTEM, INC.
CERTIFIED NURSE'S AIDE
I certify that I have not been convicted of a crime or offense that prohibits me from being granted, clinical
privileges in a long-term care setting as required by P.A. 27, 28 and 29 of 2006 within the applicable time period
prescribed by each crime.
I certify that I have not been the subject of an order of disposition under the Code of Criminal Procedure dealing
with findings of "not guilty by reason of insanity" for any crime.
I certify that I have not been the subject of a state or federal agency substantiated finding of patient or resident
neglect, abuse or misappropriation of property or any activity that caused my nurse aide certification to be
I have listed below all offenses for which I have been convicted, including all terms and conditions of sentencing,
parole, and probation and any substantiated finding of patient or resident neglect, abuse or misappropriation of
I certify that I have reviewed the list of prohibited offenses as defined in P.A. 27, 28 and 29 and that the below list of my
convictions and/or substantiated findings of patient or resident neglect, abuse or misappropriation of property (if any) is true,
correct and complete to the best of my knowledge. I also understand that if the information is not accurate or complete, my
clinical privileges will be withdrawn immediately. I understand that the facility or educational program denying my privileges
based on information retained through a background check is provided immunity from any action brought by a student due to
the decision to remove clinical privileges.