First Name
(your full legal name)

Middle Name

Last Name
(your full legal last name)

Preferred Name

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

E-mail Address

(Do not use a school email address, only use a personal email address)

Ethnicity

Race

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?

Permanent Mailing Address

Address Line 1

Address Line 2

City

State

Zip

County

Billing Preferences

Billing Name

Billing Address

Military Status

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

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?

FERPA Information

I understand that all communication about educational and general financial records will be shared with my high school.

Emergency Contact

Relationship

First and Last Name

Phone

Email

FERPA

Emergency Contact

Relationship

First and Last Name

Phone

Email

FERPA

Anticipated Enrollment Year

Anticipated Enrollment Term

High School Information

Do you attend a high school in Kansas?
(If you are Home Schooled, or attend an online high school, but reside in Kansas please select YES to this question.)

Is your high school in our Service Area?

Service Area Schools:

Select the high school:

Please enter your DCHS student ID:

Select the KS high school:

Select the high school:

MONTH:

YEAR:

Enrollment Information

This is a transfer degree in the traditional liberal arts and social sciences. It is designed to satisfy the primary general education requirements at the Regents’ universities in Kansas, while allowing for a block of elective/major hours.

Some Majors in an Associate of Arts Degree include:

This is a transfer degree in the empirical sciences. It is designed to address the primary general education requirements at the Regents’ universities in Kansas, while allowing for a block of elective/major hours

Some Majors in an Associate of Science Degree include:

Certifications & Associate of Applied Science – See Course Catalog for Details

Area of Interest – Choose One

*Upon High School Graduation, you may change your major from General Studies, to a more specific major.

Workforce/Tech Interest:

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, or Director of Human Resources, (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: