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Application For Admission (Butler Community College)

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Application
For Admission
Please use black or blue ink.
Thank you!
Mail to: Admissions
Butler Community College
901 South Haverhill Road
El Dorado, KS 67042
316.322.3255
Or apply online: butlercc.edu/enroll
Personal Information
First Name ____________________________________________ Last Name__________________________________________
E-mail Address ______________________________________________________________________________________________
Are you a U.S. citizen? ___YES ___NO (If no and you are undocumented, please continue completing this paper application for admission and print the affidavit at:
https://www.butlercc.edu/downloads/file/647/hb-2145-information-and-requirements. If you have questions, call 316.322.3382. If no and you are an international student or immigrant
permanent resident, please complete the international application at: https://www.butlercc.edu/info/201088/enrollment-checklist/270/international-student-enrollment-checklist.)
Student Type: ___ New Student: I will attend Butler after I graduate from high school (or earn my GED). If you took Butler classes while
in high school, you will re-apply as a New Student.
___ Returning Student:
I took classes at Butler in the past but have not taken classes for one semester (fall or spring)
or more and want to enroll again.
If you have been continuously enrolled at Butler (not as a high school student) you do not need to re-apply
each semester.
___ Transfer Student: I’m transferring to Butler from another college.
___ High School Student: I am currently in high school and want to take Butler classes while in high school.
If you plan
to attend Butler after you graduate from high school, you will also apply as a New Student for the semester you will start following graduation.
Legal/Permanent Address-Street__________________________________________________ Apt. #__________ PO Box_________
City____________________________________________ State___________ Zip ________________County___________________
Home Phone (_______)____________________ Cell Phone (______)_____________________ Can we text you? YES__ NO__
Mailing/Local Address_____________________________ City_____________________State___________ Zip _________________
Entry Term
Year you plan to enroll: 20_______ Semester you plan to enroll: ____Fall ____Spring ____Summer
Educational Goal Information (Please choose one.)
Fine Arts and Communication
__ Art (AA)
__ Dance (AA)
__ Mass Communication (AS)
__ Mass Communication, Journalism (AAS)
__ Mass Communication, Radio/TV (AAS)
__ Mass Communication, Sports Media (AAS)
__ Music (AA)
__ Music Education (AA)
__ Speech Communication (AA)
__ Theatre, Performance (AA)
__ Theatre, Technical (AA)
__ Fine Arts and Communication Meta Major (AA)
Business and Industry
__ Accounting (AS)
__ Accounting Assistant (AAS)
__ Agribusiness (AS)
__ Agriculture (AS)
__ Business Administration (AS)
__ Business Administrative Technology (AAS)
__ Business Medical Specialist (AAS)
__ Corporate Studies, Construction Trades (AAS)
__ Corporate Studies, Electrical (AAS)
__ Corporate Studies, Plumber and Pipetter (AAS)
__ Corporate Studies, Sheet Metal (AAS)
__ Culinary Arts (AAS)
__ Farm and Ranch Management (AAS)
__ Hotel Management (AAS)
__ Livestock Management and Merchandising (AAS)
__ Marketing (AS)
__ Marketing, Management, and Entrepreneurship (AAS)
__ Physician Coding (AAS)
__ Restaurant Management (AAS)
__ Business and Industry Meta Major (AS)
Certicates
__ Accounting Assistant (cert.)
__ Business Administrative Technology (cert.)
__ Business Medical Specialist (cert.)
__ Culinary Arts (cert.)
__ Entrepreneurship (cert.)
__ Hotel Management (cert.)
__ Livestock Management and Merchandising (cert.)
__ Physician Coding (cert.)
__ Restaurant Management (cert.)
Education and Public Services
__ Criminal Justice (AA)
__ Early Childhood Education (AAS)
__ Elementary Education (AS)
__ Elementary Education/BEST (AS)
__ Fire Science (AAS)
__ Homeland Security (AA)
__ Secondary Education (AA)
__ Secondary Education (AS)
__ Education and Public Services Meta Major (AA)
__ Education and Public Services Meta Major (AS)
Certicate
__ Early Childhood (cert.)
Certication
__ Early Childhood (CDA)
Health Sciences
__ Athletic Training (AS)
__ Exercise Science (AS)
__ Nursing (AAS)
__ Pre-Nursing/Health Sciences (AS)
__ Pre-Physician Assistant (AS)
__ Pre-Physical Therapy (AS)
__ Sport Management (AS)
__ Health Sciences Meta Major (AS)
Certication
__ Advanced Emergency Medical Technician (AEMT)
__ Butler/Cowley Partnership Paramedic
__ Emergency Medical Technician
__ Home Health Aide
__ Medication Aide
__ Nurse Aide
__ Operator Training for Assisted Living
__ Patient Care Pathways
Humanities, Social and Behavioral Sciences
__ Economics (AA)
__ Economics (AS)
__ English/Literature (AA)
__ Foreign Language (AA)
__ History (AA)
__ Liberal Arts (AA)
__ Liberal Arts (AGS)
__ Philosophy (AA)
__ Political Science (AA)
__ Psychology (AA)
__ Psychology (AS)
__ Religion (AA)
__ Sociology and Social Work (AA)
__ Humanities, Social and Behavioral Science Meta Major (AA)
__ Humanities, Social and Behavioral Science Meta Major (AS)
Science, Engineering, and Math
__ Biology (AS)
__ Chemistry (AS)
__ Engineering Technology (AS)
__ Food Science Business (AS)
__ Food Science Technology (AS)
__ Liberal Arts (AS)
__ Mathematics (AS)
__ Physics (AS)
__ Pre-Computer Science (AS)
__ Pre-Engineering (AS)
__ Pre-Medicine (AS)
__ Pre-Pharmacy (AS)
__ Pre-Veterinary (AS)
__ Unmanned Aircraft Systems (AS)
__ Science, Engineering, and Math Meta Major (AS)
Technology
__ Automotive Collision Repair (AAS)
__ Automotive Technology (AAS)
__ Cyber Security (AAS)
__ Digital Media (AAS)
__ Interactive, Digital, and 3D Technology (AAS)
__ Internetworking Management (AAS)
__ Software Development (AAS)
__ Web Development (AAS)
__ Welding Technology (AAS)
Certicates
__ Automotive Collision Repair (cert.)
__ Automotive Technology (cert.)
__ Cyber Security (cert.)
__ Digital Media Specialist (cert.)
__ Engineering Technology - Drafting (cert.)
__ Engineering Technology - Manufacturing (cert.)
__ Engineering Technology - Industrial Controls (cert.)
__ Engineering Technology (cert.)
__ Interactive, Digital, and 3D Technology (cert.)
__ Web Development (cert.)
__ Welding Technology (cert.)
Educational Information
Decision Factors
High School / GED Center ______________________________________________________________________________________
Attended from: Month_________ Year___________ Attended to: Month_________ Year___________
Graduated? ___YES ___NO Graduation Year ________
College Credit - Have you attended any other college for credit?
___YES ___NO
College _____________________________________________________________________________________
Attended from: Month_________ Year___________ Attended to: Month_________ Year___________
Graduated? ___YES ___NO Graduation Year ________
What inuenced your decision to apply to Butler Community College? (Please select one or more)
___ Academics ___ Activities ___ Alumni ___Athletics ___Butler Representative ___Butler Website
___Campus Visit ___ College Fair ___ Cost ___ Family ___Friend ___High School Counselor
___High School Visit ___Location ___ Media ___Other ___ Reputation
Anyone needing information concerning disability services should contact the Oce of Disability Services at 316.322.3321 or 733.3321 (Wichita/Metro Area).
The administration further extends its commitment to fullling and implementing the federal and state laws and regulations as specied in Title IX and Section
504 of the Rehabilitation Act. For assistance in these areas, contact the Internal Auditor, Butler Community College, 901 S Haverhill Rd, El Dorado, KS 67042;
316.323.6942.
CERTIFICATION: Please arm the following.
I understand the college may require an ocial transcript be sent from each prior institution.
___YES ___NO
All ocial transcripts on le will be used in the determination of Financial Aid eligibility.
___YES ___NO
I certify all the information is complete and correct.
___YES ___NO
Signature____________________________________________ Date____________________
NOTICE OF NON-DISCRIMINATION: Butler Community College is committed to a policy of non-discrimination involving equal access to education and
employment to all regardless of sex, race, age, religion, color, national origin or disability.
Demographic and Resident Information
Social Security Number:__________________________ Gender: ___Male ___Female Date of Birth: ____________
Month/ Day/ Year
Are you the rst person in your immediate family to attend college?
___YES ___NO
Are you a Kansas Resident? ___YES ___NO If yes, date residency began:____________
Month/Day/Year
Are you Hispanic or Latino? ___YES ___NO
Race: (Please select one or more) ___ American Indian or Alaska Native ___ Asian ___Black or African American
___Native Hawaiian or Other Pacic Islander ___White
Emergency Contact Information
Relationship________________________ First Name ___________________________ Last Name _______________________________
Phone (___________)_________________________
Street______________________________________________________ City_____________________ State_______ Zip_____________
Condentiality of Records
(If you were born in Kansas, use your birthdate.
You may be asked to show proof of residency.)
See the Family Educational Rights and Privacy Act (FERPA) listing in the current Butler catalog or on the Butler website (www.butlercc.edu)
regarding condentiality of non-directory information and how directory information can be marked for non-disclosure, as well as a list of what
is considered directory information.
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Application For Admission (Butler Community College)

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Completed 21 July 2020

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