Lehigh Valley Health Network Dependent Inquiry Form

Items marked with an asterisk (*) are required for submission.

Your Information

First Name*

Last Name*

Email Address*

Phone Number

Relationship to Dependent*

I certify that I am an employee of Lehigh Valley Health Network and am interested in learning more about DeSales University opportunities for my dependent.*

Yes

Employer (Hidden)

Employer Key (Hidden)

Your Dependent's Contact Information

First Name*

Preferred Name

Last Name*

Date of Birth*

Email Address*

Cell Phone

Mailing Address

Country

Street

City

Region

Postal Code

Your Dependent's Student Information

Student Type*

Anticipated Entry Term*

Academic Program of Interest

Level of Study (Hidden)

High School Name

High School CEEB (Hidden)

College Currently or Most Recently Attended Name

Level of Study (Hidden)

College Currently or Most Recently Attended CEEB (Hidden)