Jenzabar University

First Name
(your full legal name)

Middle Name

Last Name
(your full legal last name)

Preferred Name

Have you ever been enrolled at DCCC under a previous name?
If so, please enter your previous name(s).

Date of Birth (mm/dd/yyyy)

Gender

Social Security Number
(If none, enter 0's)

Alien Registration Number

Country of Citizenship

Cell Phone

Is it OK to text you?

Cell Phone Provider

Home Phone
(if different than your cell phone)

E-mail Address

Ethnicity

Race

Are you (the student) a veteran of the US military service?

Are you (the student) the spouse or child (dependent) of a veteran or a service member in the US military service?

Are you (the student) currently serving in the US military services - such as Active Duty, National Guard, or in the Reserves?

FERPA Information

Emergency Contact

Name

Email

Phone

FERPA

Please select which records you would like to grant access for this person:

All Records

Academic Grades

Academic Records

Accounting

Financial Aid

General Information

Registration

Emergency Contact

Name

Email

Phone

FERPA

Please select which records you would like to grant access for this person:

All Records

Academic Grades

Academic Records

Accounting

Financial Aid

General Information

Registration

Emergency Contact

Name

Email

Phone

FERPA

Please select which records you would like to grant access for this person:

All Records

Academic Grades

Academic Records

Accounting

Financial Aid

General Information

Registration

Permanent Mailing Address

Address Line 1

Address Line 2

City

Current State

Zip Code

County

How long have you most recently lived in Kansas?

Billing Preferences

Billing Name

Billing Address

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:

Please select the high school you graduated from:

High School Graduation Date

KS High School Graduation Date

Anticipated Enrollment Year

Anticipated Enrollment Term

Educational Objective

Are you interested in on-campus housing?

Degree/Major Interest:

Certification Interest:

Will you be requesting financial aid?

Have you ever been convicted of a felony?

What is the highest school completed by your Mother?

What is the highest school completed by your Father?

What type of a student will you be?

• HS Taking Dual Credit -- A current high school student taking a college credit course.
• Non-Traditional Freshman -- If this is your first time attending college and you are older than 23.
• Readmit-Previously Attended -- If you have attended DC3 in the past.
• Special-Nondegree Seeking -- If your intent is to enroll in a class for personal enrichment.
• Traditional Freshmen -- If you are a recent high school graduate attending college for the first time.
• Transfer from Another Institution -- If you have previously attended college at another institution besides DC3.
• Online Only -- All of your classes will be online.
• Unknown -- If none of these options fit your situation.

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

State the college is located in?

College 2 attended

State the college is located in?

College 3 attended

State the college is located in?

College 4 attended

Accommodation

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 offices have been designated to handle inquiries regarding the non-discrimination policies at 2501 N. 14th Avenue, Dodge City, KS 67801:

Vice President of Student Services & Risk Management/Title IX Coordinator, (620) 227-9204, Vice President of Academic Affairs/Co-Title IX Coordinator, (620) 227-9359, or Assistant Vice President of Administration & Human Resources/Co-Title IX Coordinator, (620) 227-9201. Email: compliance@dc3.edu.

Certify Form

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.

Electronic Consent

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: