Baccalaureate Dual Admission Interest Form

Dual Admission College

Community College Name:

College Account Id

Are you a member of Phi Theta Kappa?

Yes

First Name

Middle Name

Last Name

Maiden Name

Address

City

State

Zip

Citizenship

Country of Citizenship

Date of Birth

Gender Assigned at Birth

Male

Female

Cell Phone

Home Phone

Work Phone

Field of Interest

I plan to enroll in

I Plan To

Live On CampusCommute from home (of parent, guardian, spouse, or self)

High School

Year of High School Graduation

High School Account Id

I authorize my current institution and Lebanon Valley College to exchange necessary information regarding my matriculation and course work, including academic transcripts, at both institutions to facilitate the transfer from my current institution to Lebanon Valley College and to provide the information needed to evaluate the program. Such information will be reported in summary form so that no student will be identified individually.

Contact Information