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)