BACKGROUND STUDY INFORMATION FOR CNA COURSE

BACKGROUND STUDY INFORMATION FOR CNA COURSE

Students in the Wayzata High School CNA course will be attending clinical rotations at a partner site in the community. Minnesota statute requires any students with direct resident contact to complete a Department of Health Services (DHS) Background Investigation with fingerprinting. The cost of the background Check ($55) can be paid using the E-Pay link sent via ParentSquare. Students will also have to pay $10.50 to have their fingerprints completed at an approved vendor site. The sites will be communicated to students in class.
Please note that the following information will be kept strictly confidential and used solely to complete the Department of Health Services background investigation and fingerprinting process. The fields below are required as part of the Department of Health Services application.
Student Full Name

First NameMiddle Name (if you do not have a middle name, enter N/A)Last Name
Student Current/Permanent Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Prior Name or Alias
If no prior legal name (for example, previous last name), enter N/A. Do NOT enter a nickname.
Student Social Security Number
Student Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Student Place of Birth: US State or Country
Student Race
Student Gender
Student Eye Color
Student Hair Color
Student Height
Feet and inches (for example, 5’7”).
Student Weight
Pounds (for example, 150).
Student Email Address (personal email, not school email, preferred)
Please enter your PERSONAL email address, NOT your school email address.
Have you lived in any state other than Minnesota anytime since November 2020?
If you have lived outside of Minnesota in the last 5 years, list the city, state and zip code for each address where you lived. Also include the "year from and year to" for each address.
Student Driver's License or Permit Number
If you don’t have a license or permit, enter N/A.
Student Driver's License or Permit State
If you don’t have a license or permit, enter N/A.
Student Driver's License or Permit Expiration Date
Month/Date/Year (for example, 01/25/2027). If you don’t have a license or permit, enter N/A.
Student Passport Number
If you don’t have a passport, enter N/A.
If you do NOT have a driver’s license or passport, please list what legal form of government-issued photo identification you will use for this background check, AND the number and expiration date.
Please reference ID Requirements for valid forms of identification.
Student Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Student Applicant Signature
MINOR PRE-SCREENING AGREEMENT, PARENT/GUARDIAN CONSENT

I agree to allow the below listed student, who is a minor, to undergo a Criminal Background Check prior to working with senior citizens at a clinical partner site.
Parent/Guardian Signature
Should be Empty:

BACKGROUND STUDY INFORMATION FOR CNA COURSE

MINOR PRE-SCREENING AGREEMENT, PARENT/GUARDIAN CONSENT