BHA Education Program Application

NPAIHB BHA Stipend Application
Applicant Name*

First NameMiddle NameLast Name
I am applying for the:

Student Stipend (personal expenses)Student Scholarship (tuition expenses)
I am seeking education at

Heritage UniversityNorthwest Indian College
Pronouns
Tribal Affiliation
Race/Ethnicity *
Applicant Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Work Phone Number*
Cell Phone Number
Email Address*
Current Employer/Tribal Health Organization *
Hire Date
Clinical Supervisor Information (name, phone number, email)
Academic Information
High School Name *
Start and End Date
Diploma or GED?
Did you Graduate?

YesNo

NPAIHB BHA Stipend Application