Application Form

Contact Us

St. Mary Plaza

3701 Avenue D

Scottsbluff, NE 69361

United States

308-630-1155

Students may fill out the application form online below or mail the form. The reference form and observation form must be mailed or emailed to the following locations:

Regional West Medical Center
School of Radiologic Technology
4021 Avenue B
Scottsbluff, NE, 69361

Email: 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

Year

Month

Day

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

Year

Month

Day

Degree earned

First Reference - Name

First Reference - Email Address

Second Reference - Name

Second Reference - Email Address

Third Reference - Name

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 *

Year

Month

Day

Leave this field blank

Contact Us

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

Regional West

Connect With Us