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Nursing Pipeline Program Application for Fall 2026
NP²/ Nursing Pipeline Program will begin Fall of 2026
*
1.
Student Information
(Required.)
First Name
Last Name
Mailing Address
City
State
Zip Code
Date of Birth (dd/mm/yyyy)
Email Address
Phone Number
Last 4 Digits of SSN
2.
What is your gender?
Female
Male
Other (specify)
3.
Which race/ethnicity best describes you? (Please choose only one.)
American Indian or Alaskan Native
Asian / Pacific Islander
Black or African American
Hispanic
White / Caucasian
Multiple ethnicity / Other (please specify)
*
4.
School Information
(Required.)
School
GPA
*
5.
Current Grade Level:
(Required.)
Current 11th
Current 12th
*
6.
Shirt Size
(Required.)
Adult Small
Adult Medium
Adult Large
Adult XLarge
Adult 2XLarge
Adult 3XLarge
*
7.
List Any Health Career Related Activities and or classes that you are currently involved in.
(Required.)
*
8.
List any Summer Enrichment Programs or Summer Camps that you have attended. Be sure to include any other health career camps.
(Required.)
*
9.
Please use the box below to explain why you are interested in a nursing career.
(Required.)
*
10.
List and Honors or Awards you have received.
(Required.)
11.
Parent/Guardian Information (only if under 18 years of age)
Parent/Guardian Name
Relation to Student
Email Address
Phone Number
12.
By completing the names below, both student and parent (if under 18 years of age) are acknowledging the application to the program.
Student Name
Parent Name
13.
Please list any food allergies or dietary restrictions.
14.
Media Release
By checking this box, I am giving my permission to use my child's photograph and/or name for promotion of and publicity pertaining to their participation in the 2026-2027 Nursing Pipeline Program. Entities include the Southeast Kentucky Area Health Education Center, ARH, and Kentucky Community and Technical Colleges. I am aware that my child's name and photograph could be released to the local media, which could include, but not be limited to, newspapers, radio, social media, and television.
