Inside-Out Pre-Qualification Application Form

Student First Name: *

Student Last Name: *

Student ID Number: *

Date of Request (mm/dd/yyyy): *

E-mail Address: *

Home Phone: *

Mobile Phone: *

Home Address Street: *

City: *

Zip Code: *

Number of Miles from Home to Manchester, KY (Use Google to determine miles): *

Disclaimer and Signature

Note: By submitting this request, I acknowledge that I am not guaranteed approval of enrollment for the course but rather providing information for consideration. The course will be limited to a small number of EKU students and the criteria for determining which students will be admitted are based on several factors to include the date of degree completion (graduation), student organization membership and participation, education and career goals, etc. Due to the nature of this course offering, attendance of class is mandatory and will be strictly enforced.

**Students must complete an in-person interview with Dr. Lawson at the Manchester Regional Campus prior to approval. Once completing this form in totality and submitting, applicants must email Mr. Lawson (james.lawson@eku.edu) immediately to set up this interview.

**You are applying for a course that will require a background check. If you know or suspect you have felonies or outstanding warrants from any state, you will not qualify for this course and should not apply!

Student Information

Are you a current member of Alpha Phi Sigma?: *

Yes

Are you a current member of Lambda Alpha Epsilon?: *

Yes

Please list 2 current short-term goals that you may have for your education or current/future employment. (An example: I plan to join our Regional Campus CJ student honors society Alpha Phi Sigma. Or: I plan to volunteer at my local attorney's office)

Short term goal 1:: *

Short term goal 2:: *

Please list 2 current long-term goals that you may have for your education or current/future employment. (An example: I plan to attend Graduate School and work toward my Masters of Criminal Justice or I plan to work for the Bureau of Prisons)

Long term goal 1:: *

Long term goal 2:: *

List any honors and/or awards you have received, if applicable. You must be specific with the names and dates of the honors/awards so they can be considered properly.: *

Do you currently work in the criminal justice field?: *

If so, doing what and where?: *

Do you feel comfortable speaking often in group settings?: *

Have you ever been inside a correctional facility?: *

If so, give a brief description of your visit:: *

Do you have any apprehension about recurring visits inside a federal correctional institution:: *

Though not a writing intensive course, there will be writing required. Do you feel you can return essays to the instructor in a timely manner?: *

Students interested in qualifying for the course must provide a former instructor’s name and number for Dr. Lawson to contact for reference. Note: Please do not list us (EKU Criminal Justice Faculty)

Name:: *

Number:: *

*Note: Application will not be considered if all questions are not answered. Please note that all questions must be answered. If there are any questions that are not applicable, please put N/A in that section.

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