Application Form

Location

St. Mary Plaza

3701 Avenue D
Scottsbluff, NE 69361
United States

Get in touch

Students may fill out the application form online below. The application deadline is the first business day of February. There is no application fee. The observation form must be emailed to: RadiologySchool@rwhs.org

The application deadline is the first business day of February. There is no application fee.

Name

Email Address

Street Address

City

State

Zip Code

Country

Phone Number

Last High School Attended

Address of High School

Date completed high school diploma or GED equivalency

Date completed high school diploma or GED equivalency: Year

Date completed high school diploma or GED equivalency: Month

Date completed high school diploma or GED equivalency: Day

Please request your official high school transcripts be mailed or electronically sent directly to the program from your high school. Transcripts must be received by Feb. 20th. Please email transcripts to Karen.Prouty@rwhs.org, or mail them to: Regional West Medical Center, School of Radiologic Technology, 4021 Avenue B, Scottsbluff, NE 69361

Most Recent College Attended

Number of semesters attended at most recent college

Years attended at most recent college

Second College Attended (if applicable)

Number of semesters attended at second college

Years attended at second college

Date of graduation from college

Date of graduation from college: Year

Date of graduation from college: Month

Date of graduation from college: Day

ALL OFFICIAL COLLEGE TRANSCRIPTS MUST BE SENT DIRECTLY TO THE PROGRAM FROM THE ATTENDED COLLEGE. Please have them sent electronically to Karen.Prouty@rwhs.org. If mailing is the only option, please email the program and let them know they are coming by mail. ALL TRANSCRIPTS MUST BE RECEIVED BY FEBRUARY 20TH.

Degree earned

First Reference - Name

The reference listed above will be emailed a link to a reference check survey. Please let them know this email is coming and ask them to respond promptly.

First Reference - Email Address

Second Reference - Name

The reference listed above will be emailed a link to a reference check survey. Please let them know this email is coming and ask them to respond promptly.

Second Reference - Email Address

Third Reference - Name

References listed above will be emailed a link to a reference check survey. Please let them know this email is coming and ask them to respond promptly.

Third Reference - Email Address

I hereby certify that the above information is true to the best of my knowledge

Yes

I hereby certify that I have read the Technical Standards, found under the Policies tab to the left

Yes

Do you feel you need accommodations for any of the information listed in the Technical Standards?

Yes

Signature

Date

Date: Year

Date: Month

Date: Day

Primary Care

Urgent, Emergent, and Trauma Care

Specialty Care

Location

Get in touch

The application deadline is the first business day of February. There is no application fee.

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