LIFE Application | NorthWest Arkansas Community College

If you see this don't fill out this input box.

First name*

Middle Initial*

Last Name*

Date of birth*

Gender

Male

Female

Home Address*

City *

State

Arkansas

Missouri

Oklahoma

Zip*5 digit zip code

Email*

Home phone number

Cell Phone (LIFE official form of communication)*

Language(s) spoken in home if other than English

Ethnicity (select all that apply)

Hispanic Latino

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or other Pacific Islander

White

Other

If other, please indicate

Parent/Guardian Information/Emergency Contact

First name*

Last name*

Relationship to applicant*

Primary phone number*

Secondary phone number

Home address*

City*

State

Arkansas

Missouri

Oklahoma

Zip*

Program Details

Please indicate your shirt size (We can not guarantee that shirts will be provided this year)

Adult small

Adult medium

Adult large

Adult XLarge

Adult XXLarge

Adult XXXLarge

Do you require assistance or accommodation due to a disability

Yes

If yes, please indicate

Limited vision or blindness

Hearing loss or deafness

Wheelchair access or other mobility related need

Other

If other type of accommodation, please indicate

Education Information

Current Grade

Freshman

Sophomore

Junior

Senior

SENIORS ONLY: Please check all of the following that apply to you regarding your plans for after graduation

You have already applied for admission to NWACC

You are interested in applying for admission to NWACC in the near future

You plan on attending another college or university

You do not plan on going to college at this time

SENIORS ONLY: Would you be willing to connect with LIFE Staff and Mentors through one or more of the following ways: email, cell phone, social media, Zoom, etc.

Yes

Not really

If not really, please explain why

Do you already have an idea of what you would like to study in college?

Do you participate in any of the following programs (check all that apply)

Youth Strategies

Camp War Eagle

Upward Bound

Razor COACH

None of the above

About You

How did you hear about the LIFE Program? (select all that apply)

Social media such as Instagram Facebook Snapchat Twitter

School counselor

Teacher

NWACC staff

LIFE mentor

NWACC student

Friend

Other

If other, please indicate

Name of friend, school counselor, teacher, NWACC staff, mentor or student that told you about the LIFE program

How can the LIFE program best communicate virtually with you at this time?

Text

Zoom

Hangouts

Social media

Other

If other, please list

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LIFE Program