Bryan College of Health Sciences at Northwest High School

Here are some things you will be asked for in order to complete your application: 1. Student contact information 2. Parental consent and contact information 3. References (one is required) their names, email addresses, and phone numbers. Teachers and/or Counselors may be contacted for information on fit for the Program

1. Student Contact / Personal Information

Student ID*

Student Legal First Name*

Student Legal Last Name*

Current School Attending*

Select

Current Grade Level*

Select

2. Parent Consent & Contact Information

Parent First Name*

Parent Last Name*

Parent Email*

Parent Mobile Phone*

Phone

3. References

One reference is required and a second is optional. Please provide their contact information including their name, email, and phone number. References need to be teachers, counselors, Teammate Mentor or other school professionals. Please do not use family and friends as references.

Reference Name # 1 (First & Last Name)*

Reference Email # 1*

Reference Phone # 1*

Phone

Reference Name # 2 (First & Last Name)

Reference Email # 2

Reference Phone # 2

Phone

I give consent for my contact information (name, email, mailing address, phone number) and the LPS school email of my child to be provided to Katherine Karcher, Bryan College of Health Sciences Focus Program Director.*

Yes

Payment Options*

A. Pay upon receiving statement.

When I receive my statement, I plan to pay by check, money order, or credit card.

B. Applying for the ACE scholarship.

I plan to apply for the ACE scholarship, which is based on financial need (https://ccpe.nebraska.gov/ACE). I will contact my high school counselor if I need assistance with this application. I understand that I will continue to receive monthly billings until the scholarship has been awarded. If I am not awarded this scholarship, I will pay for the class, or notify the Bryan College of Health Sciences of my intention to drop the class.

C. Be considered for assistance from the Medical Sciences Focus Program Scholarship from Bryan Foundation.

If you do not qualify for the ACE scholarship, but would still like to be considered for financial assistance, please select this option and your high school counselor will contact you with more information.

Please select a Payment Option:

Pay upon receiving statement

Apply for the ACE scholarship

Apply for the Medical Sciences Focus Program Scholarship funded by Bryan Foundation

Send me a copy of my responses

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