Online Application

denotes required fields.

Contact Information

Last Name

First Name

Birthdate

Phone Number

Address 1

Address 2

City

State

Zip /Postal Code

Country

If not a U.S. citizen, are you a permanent resident of the U.S.?

Yes

Are you your own guardian?

Yes

Parent/Guardian Contact Information

Last Name

First Name

Relationship to Student

Phone Number

Address 1

Address 2

City

State

Zip /Postal Code

Country

Education History (include high school(s) and colleges or universities)

School 1

Name of School

City, State

Date started

Graduation Date or Reason for Leaving

School 2

Name of School

City, State

Date started

Graduation Date or Reason for Leaving

School 3

Name of School

City, State

Date started

Graduation Date or Reason for Leaving

Diploma or Certificate

Name of diploma or certificate received

Date receieved

Support Services

Student receives support or services from: Check all that apply and indicate if you are on a waiting list.

If you selected "other" or are on a waiting list, please specify:

Did you participate in general education classes during high school?

Yes

If yes, please list inclusive classes:

Please describe your academic strengths.

Please describe your academic challenges.

How do you think you learn best?

Please describe any accommodations used in school.

Are there any assistive tools that you use regularly?

Yes

If yes, please explain:

Work History

Job 1

Name of Employer or Organization

Job Title

Volunteer or Paid

Volunteer

Paid

Job Duties

Start date

End date

Job 2

Name of Employer or Organization

Job Title

Volunteer or Paid

Volunteer

Paid

Job Duties

Start date

End date

Job 3

Name of Employer or Organization

Job Title

Volunteer or Paid

Volunteer

Paid

Job Duties

Start date

End date

Job 4

Name of Employer or Organization

Job Title

Volunteer or Paid

Volunteer

Paid

Job Duties

Start date

End date

Job 5

Name of Employer or Organization

Job Title

Volunteer or Paid

Volunteer

Paid

Job Duties

Start date

End date

Work Information

Have you received job coaching during your work experience?

Yes

Have you ever been fired from a job?

Yes

If yes, please explain:

Have you ever quit a job?

Yes

If yes, please explain:

Have you ever had difficulty getting along with a supervisor, co-worker or a customer on a job?

Yes

If yes, how did you handle that?

Please list how you are currently occupied (school, work, volunteer, support services activites, etc.):

Activity 1

Activity

Time Day of week, Hours.

Provider (if applicable)

Activity 2

Activity

TimeDay of week, Hours.

Provider (if applicable)

Activity 3

Activity

TimeDay of week, Hours.

Provider (if applicable)

Activity 4

Activity

TimeDay of week, Hours.

Provider (if applicable)

Activity 5

Activity

TimeDay of week, Hours.

Provider (if applicable)

Student Questionaire

Why do you want to be a MSU LIFE Scholar?

What classes are you interested in taking?

What social activities, clubs or events are of interest to you?

What are your future career goals after college? What type of job would you like?

How do you want to be employed in the community upon completion of your college experience?

Full-time

Part-time (16+ hrs./week)

What are your future living goals? Do you want to live on your own, with a roommate or your family?

Please use this space to share anything else about yourself that you'd like us to know.

Student Skills Assessment

Applicant's Name

Date

Please use the following scale to document your skill level in each area. The document may be completed with input from parents or guardians.

1 = I need total support.
2 = I need some support.
3 = I am independent.

Required Safety & Security Information

In the interest of campus safety, the following questions are asked of all applicants. Answering “yes” to any of these questions will not automatically prevent admission. Each application is reviewed and evaluated on an individual basis. You will have an opportunity to respond and provide additional information to be reviewed by the Campus Safety Questionnaire Review Committee. Any falsification or omission of information may result in a denial of admission or referral to the Office of the Dean of Students.

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Online Application

LIFE Scholars

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