Lehigh County District Attorney Career Pathway Scholarship

Student Referral Form

Student Name(Required)

First Last

Student Phone Number(Required)

Student Email(Required)

Student Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Referring Agency(Required)

Student will need additional education support prior to starting the program. Select option that best describes the students needs.(Required)

ESL

GED

Both ESL and GED

None of the above

Select one type of educational program the student noted above is interested in pursuing:(Required)

Credit Program (Associate Degree Seeking Programs)

Non-Credit Program (Certificates, Certifications & Licenses)

Select one background that best describes the student noted above:(Required)

Student must have past history of Opioid Use Disorder (OUD), any co-occurring substance use disorder or Mental Health (SUD/MH) condition.

Student must have experienced personal hardships and/or incarceration resulting from drug and/or alcohol use.

None of the above

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