SouthArk JAG Bridge Program June 4th & 5th
To apply for this free program, please fill out and submit this application by the deadline, May 22nd 2025. Your application will be reviewed, and you will be notified of your acceptance or non-acceptance into the program via email and/or phone number given in the application. If you have any questions regarding the application or program, please contact Dana Lawrence at ddlawrence@southark.edu/ 870-864-8432/Work cell (318)523-0779
Student Name
First Name
Last Name
Student Status
Senior - Graduating Spring 2025
Junior - Graduating Spring 2026
What high school do you currently attend?
Student Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student E-mail
example@example.com
Student Phone Number
Format: (000) 000-0000.
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Next
All information shared within this application will remain confidential
Which of the following best describes your current living situation?
Live with both parents
Live with Friends
Live with Mother
Live by myself
Live with Father
Live with partner
Live with Relative
Choose Not to Answer
Live with Foster Parent
Other
Number of persons in household including yourself:
Select all that apply to you:
Currently enrolled in JAG high school class
A parent or expecting parent
Been convicted of a criminal offense (other than a traffic violation)
Have a record of violent behavior
Have documented alcohol and/or substance abuse
Have your own vehicle
Mother has completed 4 year college degree
Father has completed 4 year college degree
Neither parent has completed a 4 year college degree
Both parents have completed a 4 year college degree
Eligible for Temporary Assistance for Needy Families (TANF)
English Learner
Have documented disability
Have poor attendance record
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Next
Parent or Guardian Contact Information
First Name
Last Name
Parent or Guardian E-mail
example@example.com
Parent or Guardian Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Student Signature
Student Signature Date
-
Month
-
Day
Year
Date
Parent Signature
Parent Signature Date
-
Month
-
Day
Year
Date
Submit Application
Should be Empty: