2026-2027 CHARGE- Collegiate Nursing Programming Application

2026-2027 CHARGE-Collegiate Programming Application

General Information
Full Name*

First NameLast Name
Preferred Name*
Gender*

MaleFemaleOther
Birth Date*

MonthDayYear
E-mail*
example@example.com
Preferred Contact Number*
Format: (000) 000-0000.
Permanent Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How did you hear about this program?*
Emergency Contact Information
Full Name*

First NameLast Name
Relationship to Applicant*
Permanent Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone*
If none, put 000-000-0000Format: (000) 000-0000.
Cell Phone*
If none, put 000-000-0000
Work Phone*
If none, put 000-000-0000
E-mail*
example@example.com

College/University Information

Please fill in the blanks below with information on your current school enrollment.
Name of College/University*
County of College/University*
Location of College/University*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Current Education
What is your current GPA?*
What is your current grade level? NOTE: This program is only available to those currently enrolled in a collegiate/university nursing program and actively taking classes within the program*

College FreshmanCollege SophomoreCollege JuniorCollege Senior
When is your anticipated graduation date?*
Please select your program*
Please upload a current unofficial copy of your collegiate/university transcript*

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Written Response Questions
List any current Health Career related activities that you are involved in*
If none, put N/A.
Extracurricular Activities: List any extracurricular activities you have been in or currently involved with and provide a description of your contribution to that activity. Also provide the calendar year(s) in which you participated in each activity*
If none, put N/A
Service (voluntary or paid): List your volunteer or paid work experience. Explain your specific responsibilities and date(s) completed or currently working*
If none, put N/A
Honors/Awards (BE SPECIFIC): List any honors and awards that you have received. Please do not list involvement in organizations and clubs unless you have been elected to an office or selected for a specific honor. Do no abbreviate award names. For example: Write National Honor Society, not NHS. Also include the year(s) in which you received the honor or award*
If none, put N/A
Please upload ONE of the following options: 1) Video: Upload a short, 3 to 5 minute video speaking about your background, interests, and goals within the nursing career field. Explain why you are wanting to enter this programming and why you believe it will assist you in achieving your goals. Please dress appropriately if you chose this option and record the video with the camera on and minimal background noise. -OR- 2) Essay: Please upload a personal essay of 500 words or less about your background, interests, and goals within the nursing career field. Explain why you are wanting to enter this programming and why you believe it will assist you in achieving your goals. This allows the application review committee to get a better understanding an applicant's personality and expectations. Please double-space your writing entry and attach here*

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Professor Letter of Recommendation Acknowledgement

*REQUIRED FIELD*
This letter of recommendation should be on official letterhead, signed by the reference writing the letter, and include the direct contact information of the reference. This letter can come from a variety of educational mentors (i.e. professors, clinical instructors, lab coordinators, etc...). Please submit the letter below, email to Lakyn Newcomb at Lakyn.Newcomb@uky.edu, or have your recommender upload the letter on the NE KY AHEC website under the recommendation letter upload form. You are encouraged to submit your application as soon as possible- the letter can be sent in anytime prior to application close. Your application will not be considered complete until this letter is received. If you have trouble getting the letter completed on time, please reach out to Lakyn.Newcomb@uky.edu for assistance as we may be able to work with you.*

Yes, I understand my letter must be received prior to the application close date in one of the manners listed above in order for my application to be considered complete.
If you already have your letter of recommendation you can upload it here. Please only use Microsoft Word or PDF files if possible.

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By signing my digital signature, I hereby certify that the information provided on this application and attachments I have provided is true and accurate to the best of my knowledge and that the writing entry is my original work. I understand that if all sections of this application are not completed and if all additional paperwork needed is not submitted to Northeast AHEC prior to the application close date, my application will be automatically denied and I will no longer be considered an applicant for this program. I commit myself to abide by the rules and expectations of this program.*
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2026-2027 CHARGE-Collegiate Programming Application

Emergency Contact Information

College/University Information

Current Education

Written Response Questions

Professor Letter of Recommendation Acknowledgement