Recommitment Form

Complete and submit this form by September 1st to be re-eligible for the JALC Promise Scholarship. After you submit the form, you will receive a confirmation sent to the email you provide. If you have questions about this form, please email promise@jalc.edu.

Student Name: *

First

Last

Date of Birth: *

Student High School ID Number: *

High School

Expected High School Graduation Month and Year: *

Mailing Address: *

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Student Cell Phone: *

Parent/Guardian Phone: *

Student Personal Email Address: *

Email

Confirm Email

Parent/Guardian Email Address: *

Email

Confirm Email

Confirmation

• I confirm that the above information is true.

Submit