VUJ: Patoka Valley Application

Submitted Date

Student Type

Round (Term)

Major

Educational Goal

Are you part of Patoka Valley Program

Yes

No

Campus

First Name

Preferred Name

Middle Name

Last Name

Mailing Address

Country

Street

City

Region

Postal Code

Permanent Address

Same as Mailing Address

Country

Street

City

Region

Postal Code

Birthdate

Email Address (please do not use your school email address)

Mobile Number

Gender

Ethnicity: Are you Hispanic or Latino?

Country of Citizenship

US Residency Status

High School Information

High School Graduation or GED/TASC Date

HS CEEB Code

High School Name

Level of Study

Degree

What pathway are you interested in?

Emergency Contact

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Relationship

Emergency Contact Phone

Emergency Contact Email

Release of Information

Contact for an Emergency (Hidden)

College Expulsion/Suspension

*Have you ever been expelled or academically disqualified from VU?

Yes

No

*Have you ever been dismissed from any other institution for disciplinary reasons?

Yes

No

*University/college at which the incident occurred:

*In your own words, please provide the date and explain the events that lead to the expulsion/suspension.

Felony Charge

*Have you ever been adjudicated guilty or convicted of a misdemeanor, felony, or other crime?

Yes

No

*Please indicate the felony charge:

*In your own words, please provide the date and location of the incident(s) and explain the events/circumstances leading to the felony charge.

Signature

I release permission for VUJ to communicate with personnel at my high school, Patoka Valley CTE Cooperative, and internship site as needed for participation in the VUJ/Patoka Valley dual credit program.

Yes

No

I understand that to register for courses with prerequisites, I must meet the same academic guidelines as degree-seeking students and that I may be required to take a college placement exam.

Signature