ARKANSAS RESIDENTIAL ASSISTED LIVING ASSOCIATION

692 HONEYSUCKLE LANE

CABOT AR 72023

501-941-2075

 

ADMINISTRATOR CERTIFICATION PROGRAM

STUDENT REGISTRATION FORM

 

 

NAME:                                                                                                                        DATE:

 

 


FACILITY:

 


                        LICENSED RCF/ALF              IN PROGRESS              NOT FACILITY ASSOCIATED

 

ADDRESS:                                                                 

 

 

CITY:                                                                                                  ST:                   ZIP:

 

 

TELEPHONE NUMBER:                                  FAX:                                EMAIL:

 


MEMBERSHIP STATUS:         FACILITY         ASSOCIATE         NONMEMBER

                                                   GOOD STANDING            JOINING TODAY

 

SOCIAL SECURITY NUMBER                     --         --                        DATE OF BIRTH

 

 


AGE:                            SEX:                            RACE:

 


EDUCATIONAL LEVEL:           HIGH SCHOOL/GED       SOME COLLEGE       COLLEGE GRAD

        HIGHEST DEGREE HELD                NURSING OR SOCIAL WORK

 

 

WORK HISTORY:

Please indicate any and all of the areas in which you have had experience by entering the approximate amount of time you have worked in that position.

 

RCF/ALF            NURSING FACILITY          HOSPITAL          HOME HEALTH              HOTEL                FOOD SERVICE/RESTAURANT           OTHER HOSPITALITY   

COMMERCIAL HOUSEKEEPING         MAINTENCE

 

 

I understand that to be eligible to work as an administrator of a Residential Care Facility or Assisted Living Facility in the state of Arkansas that I must meet certain requirements established by law and regulation and that successful completion of this program fulfils only the certification requirement.  I also understand that the Arkansas Residential Assisted Living Association assumes no responsibility for any consequences attributed to or related to any use or interpretation of any information or views presented through this training program.

 

 

 


                                                       Signature                                                   (office use)