First Name (your full legal name)
Last Name (your full legal last name)
Have you ever been enrolled at DCCC under a previous name? If so, please enter your previous name(s).
Date of Birth
Social Security Number(If none, enter 0's)
Alien Registration Number
Country of Citizenship
Is it OK to text you?
Cell Phone Provider
Home Phone(if different than your cell phone)
Are you a Veteran who has served on Active Duty, National Guard, or a Reserve component of the US Military Service?
Are you a spouse or dependent of a Veteran who has served on Active Duty, National Guard, or a Reserve component of the US military service?
Is your parent, guardian, or spouse currently on Active Duty in the Army, Navy, Air Force, Marine Corps, or Coast Guard?
Is your parent or guardian currently on Active Duty, National Guard, or a Reserve component of the US Military Service?
Are you currently serving on Active Duty, or currently in the National Guard, or currently in the Reserve component of the US Military Service?
Please select which records you would like to grant access for this person:
Permanent Mailing Address
Address Line 1
Address Line 2
How long have you most recently lived in Kansas?
Did you attend high school in Kansas?(If you have a GED or you are Home Schooled, please select YES to this question.)
Please select the high school you graduated from:
High School Graduation Date
KS High School Graduation Date
Anticipated Enrollment Year
Anticipated Enrollment Term
Area of Interest
Are you interested in on-campus housing?
Will you be requesting financial aid?
Have you ever been convicted of a felony?
What is the highest school completed by your Father?
What is the highest school completed by your Mother?
What type of a student will you be?
Enter the last four colleges, universities and/or technical schools you have attended. (You must request an OFFICIAL transcript be sent to DCCC from the institution(s) you have attended.)
Have you ever been academically dismissed from a higher education institution?
State the college is located in?
College Most Recently Attended
College 2 attended
College 3 attended
College 4 attended
Please see the page https://dc3.edu/policies/accommodations-for-students-with-disabilities/ for accommodations.
Notice of Non-Discrimination
Dodge City Community College does not discriminate on the basis of race, color, national origin, sex, disability or age in its programs and activities. The following persons have been designated to handle inquiries regarding the non-discrimination policies:
Federal Compliance Administrator, 2501 N. 14th Avenue, Dodge City Kansas 67801, (620) 227-9119 (email@example.com)
Director of Human Resources, 2501 N. 14th Avenue, Dodge City Kansas 67801, (620) 227-9201, (firstname.lastname@example.org)
I certify the information I have provided in this application is true and correct. I understand that submission of false or incomplete information may result in denial of admission or suspension if enrolled. If accepted as a student at Dodge City Community College, I agree to abide by all rules concerning conduct, financial aid and other obligations.
I consent to receive information electronically: (I understand declining electronic consent may significantly increase the time it takes to process my application.)
Submit Your Application
Send an email acknowledgment of this submission to this email address: