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Certified Medical Assistant Class Interest Form

Questions marked with a * are required

Thank you for your interest in a Certified Medical course through Bismarck State College. Please use the form below to submit your contact information.

Contact Information

First Name

Last Name

Phone

Email Address

Mailing Address

City

State

Zip Code

A current Certified Nursing Assistant license is strongly recommended prior to taking the CMA course. Please indicate below your status:

I am an active CNA

I have a CNA license

I am interested in CNA training also

I am interested in attending class:

Spring

Fall

Next Available

To complete the CMA course, you will need proof of immunization for the following:

- Varicella (Chickenpox)

- Measles, Mumps, Rubella

- Tuberculosis

- Influenza

- Hepatitis B Series (optional with a signed waiver)

- COVID-19 vaccination status must be disclosed due to federal reporting requirements of clinical facilities. Vaccination is optional, however, it may be required based on clinical facility placement.

Please indicate if you understand this requirement.

Yes

Completing this form does not mean you are registered for the course, but it will provide a means of communication when more course details are in place.

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