Please complete this questionnaire to let us know a bit more about yourself and your interest in the Distance Education option for the Radiation Therapy program at Northwestern Health Sciences University.

First Name

Last Name

Phone

Email

Mailing Address Line 1

Mailing City

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Zip Code

What is your highest level of education? High school diploma/GED Some college/No Degree Associates Degree Bachelor's Degree Graduate/Professional Degree

Best estimate of your High School GPA

Best estimate of your College GPA

How did you hear about us? Advisor (High School/College) Alumni Assoc of American Medical Colleges College/Career Fair Current Student Friend/Family AI Online Ad Other Social Media Social / Community Event Web Search

Do you have a clinical affiliation established? I have a clinical affiliate identified I need help identifying a clinical affiliation site (not guaranteed)

Please provide the information for your clinical affiliation (put NONE if you do not have one identified)

If you are unable to secure a clinical affiliation, are you interested in relocating to attend in person at NWHSU, in Bloomington, Minnesota? No Yes Possibly

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