2024-2025 CHARGE- High School Nursing Programming Application

2024-2025 CHARGE-High School Programming Application

General Information
Full Name*

First NameLast Name
Preferred Name*
Gender*

MaleFemaleOther
Birth Date*

MonthDayYear
E-mail*
example@example.com
Preferred Contact Number*
Permanent Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How did you hear about this program?*
Please select your shirt size (Unisex sizing: please be accurate when selecting your size)*

Adult SmallAdult MediumAdult LargeAdult X-LargeAdult 2X-LargeAdult 3x-Large
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 000-000-0000
Cell Phone*
If none, put 000-000-0000
Work Phone*
If none, put 000-000-0000
E-mail*
example@example.com

High School Information

Please fill in the blanks below with information on your current school enrollment.
Name of High School*
County of High School*
Location of High School*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Current Education
What is your current GPA?*
What is your current grade level?*

High School JuniorHigh School Senior
Please upload a current unofficial copy of your high school transcript*

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Written Response Questions
List any current Health Career related activities and/or classes that you are involved in*
If none, put N/A.
School-Based Extracurricular Activities: List any extracurricular activities you have been in or currently involved with through your school 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 or 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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Reference

*REQUIRED FIELD* Please list three (3) professional references below that we may contact that will speak on your behalf.
REFERENCE #1*

First NameLast Name
Organization/Company*
Relation to Applicant*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
REFERENCE #2*

First NameLast Name
Organization/Company*
Relation to Applicant*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
REFERENCE #3*

First NameLast Name
Organization/Company*
Relation to Applicant*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
By selecting "I understand" below, I understand that I am giving the Northeast AHEC permission to contact the above references on my behalf. I understand the contact may include the Northeast AHEC asking the reference about my work ethic as well as any other questions in direct relation to my application to this program.*

I understand

Parental Consent: Upload Consent Form Acknowledgement

*REQUIRED FIELD*
If you are under the age of 18, a legal guardian must complete and upload a parental consent form through the parental consent upload tab on the Northeast Kentucky AHEC site under the Nursing Pipeline-High School section. If you are under 18, you will not be eligible to participate in the program without parental consent completed and your application will be disregarded.*

Yes, I understand my legal guardian must complete and upload a parental consent form prior to the application close date on the application site listed above in order for my application to be considered complete.
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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2024-2025 CHARGE-High School Programming Application

Emergency Contact Information

High School Information

Current Education

Written Response Questions

Reference

Parental Consent: Upload Consent Form Acknowledgement