Lehigh County District Attorney Career Pathway Scholarship

Student Referral Form

Student Name(Required)

First Last

Date of Birth(Required)

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)

Opioid Scholarship Confirmation(Required)

By selecting this box you have confirmed this potential student has a past history of Opioid Use Disorder (OUD), any co-occurring substance use disorder or Mental Health (SUD/MH) condition.

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