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Opportunity Scholars Student Application
Today's Date
*
-
Month
-
Day
Year
Date
Student Name
*
First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
Date
Student's Phone Number
*
Student's Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Parent/Guardian Email
*
example@example.com
Ethnicity (select one)
*
Hispanic or Latino
Not Hispanic or Latino
Race (select one)
*
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Gender
*
Male
Female
Non-binary
School currently attending
*
Grade
*
Did you graduate?
*
Yes
No
Diploma
High School Diploma
GED or equivalent
Certificate
Associate's Degree
Bachelor's Degree
What is your career goal? Mark one that best describes your career.
*
Accounting
Computer/IT
Education
Engineering
Healthcare
Trades/Technical
Non-pathway (unsure)
Other
Do you plan to attend college locally (LRCC or Shenandoah University)?
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Yes
No
Are you a citizen of the United States?
*
Yes
No
Do you have a legal work authorization in the US?
*
Yes
No
Do you see yourself working in the community (Northern Shenandoah Valley area) upon completion of higher education?
*
Yes
No
How did you hear about us?
*
Social Media
Website
School
Friend
Other
Parent/Guardian Signature
Student Signature
*
Date
-
Month
-
Day
Year
Date
Save
Submit
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