2026-2027 CHARGE- High School Nursing Programming Application

2026-2027 CHARGE-High School Programming Application

General Information
Full Name

First NameLast Name
Preferred Name
Gender

Other
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?
Please select your shirt size (Unisex sizing: please be accurate when selecting your size)
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

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 will your grade level be as of this Fall 2026?
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 up to 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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Letter of Recommendation

Please upload one (1) recommendation letter for the application committee to review.
Upload your letter of recommendation here. Letter needs to be submitted as either a Word document or as a PDF. If you need to upload your letter at a later time please email it to Lakyn.Newcomb@uky.edu.

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Letter written by:

First NameLast Name
Organization/Company
Relation to Applicant
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Organization/Company
Relation to Applicant
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
REFERENCE #3

First NameLast Name
Organization/Company
Relation to Applicant
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
By selecting "I understand" below, I understand that I am giving the Northeast AHEC permission to contact the above letter writer if any questions regarding my recommendation arise. I understand the contact may include the Northeast AHEC asking the writer about my work ethic as well as any other questions in direct relation to my application to this program.
Parental/Guardian Consent
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.
Acknowledgment
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-High School Programming Application

Emergency Contact Information

High School Information

Current Education

Written Response Questions

Letter of Recommendation

Parental/Guardian Consent

Acknowledgment