Opportunity Scholars Student Application

Opportunity Scholars Student Application
Today's Date *

Month Day Year
Date
Student Name *

First Name Last Name
Date of Birth *

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
What is your career goal? Mark one that best describes your career. *

Accounting Computer/IT Education Engineering Healthcare Trades/Technical Non-pathway (unsure)
Do you plan to attend college locally (LRCC or Shenandoah University)? *

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
Parent/Guardian Signature

Clear
Student Signature *

Clear
Date

Month Day Year
Date
Should be Empty:

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