Name: ______________________________________________________________________________
(Last) (First) (Middle Initial) (Maiden)
Address: _____________________________________________________________________________
City: ___________________________ State: _____ Zip Code: ___________ County: _______________
Day phone: (___) ________________ Cell: (___) _________________ Birthdate: ____________________
e-mail address: ___________________________ Student ID or SSN ______________________
(Voluntary)
Are you a resident of the state of Minnesota? Yes No # of yrs _________ mo __________
Are you a U.S. Citizen? Yes No If you answered no, which category below best fits your status:
Resident Aien Refugee/Asylee Temporary protected status None of these
Are you currently or have you ever served in the Armed Forces for the United States Yes No
Have you ever attended DCTC before? Yes No If yes, approx. last date of attendance ___________
Additional information about Nursing Assistant:
• Students must complete the Reading Comprehension portion of the Accuplacer
Assessment (Recommended Score 50 or above) or have completed a college level
English course.
• Books and supplies can be purchased in the bookstore – list of required items are
available at www.dctcbookstore.com
• Be prepared to complete a background check on the first day of class (credit card
payment for approx. $20 is required)
• Upon completion of the course (for an additional cost) you will be eligible to take the
NNAAP Exam.
• Be aware that the Nursing Assistant Certificate does not meet the criteria for being
financial aid eligible.
• If plans change and you are not able to attend the section you registered for, you
MUST officially drop the course on or before one business day after it begins to not be
financially and academically responsible for the course.
• Final payment for the course is required prior to signing up for the state exam.
--Over--
Nursing Assistant Application and Registration Form
Semester of Registration Year
PLEASE PRINT Fall Spring Summer
Scheduled courses are able to be viewed at www.dctc.edu at the bottom of the home page under Student
Links. Search under subject HEAL. Fill in the course ID and section number of desired course.
COURSE REGISTRATION INFORMATION
Course ID
Subject/Course
#
Section
Credits
Est.
cost
HEAL 1060
5
Estimate cost: For cost estimates please refer to the course schedule Estimated cost of courses
on our web site at www.dctc.edu.
One time Non-refundable $ 20
Students will be notified if the class they choose is filled or cancelled. application fee
By signing below I accept financial responsibility for course(s) for which I register and
I understand the drop/add policy.
Details can be referenced on-line at: http://www.dctc.edu/admissions/pay-for-college/tuition-fees/withdrawals-
refunds/
Student: __________________________________________________ Date: ________________________
(Signature)
Payment Options: You must choose a payment option to complete registration.
Full Payment:
Checks payable to Dakota County Technical College can be mailed with completed registration form to:
Dakota County Technical College, Attention: Registration, 1300 145
th
St. E. (County Road 42), Rosemount, MN 55068.
Credit Card: Please Charge my full balance due. o VISA o MasterCard o Discover
Card number _______________________________________Expiration Date: ____________________
Signature of Cardholder _______________________________________________________
o Payment Plan: I am interested in a payment plan to spread out the cost of classes. I know I MUST enroll through the E-cashier link
on the college website (www.dctc.edu). I am aware of the pay dates and fees associated with the payment plan.
*Optional – Used for statistical purposes only:
High School Graduate: Ethnicity/Race 1. Black, Non-Hispanic
YES Year: ____________ NO 2. American Indian/Alaskan Native
GED Yes No 3. Asian/Pacific Islander
Gender: Male Female 4. Hispanic
5. White, Non-Hispanic
Are you a displaced homemaker? Yes No Single parent? Yes No
*Note to student:
The information collected in the optional section is needed for reporting and research purposes only. It will be kept
confidential and will not used as a basis for enrollment, or in a discrminatory manner. The information collected will be
used for summary reports required by federal and state laws and regulations to support institutional affirmative action.
Summary reports do not identify individuals. Completion of this section is voluntary. Refusal to provide any of the
requested information will not affect your enrollment. Students with disabilities are encouraged to contact the
Supplemental Services Coordinator to arrange appropriate services.