Lehigh County Resident Scholarship Referral Program

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

Lehigh County Resident(Required)

By clicking this button you certify this student referred above has a Lehigh County address.

Referring Agency(Required)

Name of referring agency representative making this referral.(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 Past History 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.

By selecting this box you have confirmed this potential student has NO past history of Opioid Use Disorder (OUD), any co-occurring substance use disorder or Mental Health (SUD/MH) condition.

Select the appropriate scholarship request:(Required)

District Attorney Career Pathway Scholarship. (By selecting this scholarship you have confirmed this potential student is a current Lehigh County resident with a past history of opioid use disorder (OUD), any co-occuring substance use disorder or mental health (SUD/MH) condition.

Promise Program Scholarship (By selecting this scholarship you have confirmed this potential student is a current Lehigh County resident.)

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Lehigh County Resident Scholarship Referral Program

Student Referral Form