Application for Admission Colby Community College Dental Hygienist Program
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Name_____________________________________
________________________Telephone__________________
(L
ast) (First) (Middle) (Maiden)
Home Address________________________________________________________________________________
(Street) (City) (State) (Zip)
Active E-mail address__________________________________________________________________________
Birthdate_________________________________________________________ Sex: Male_____ Female _____
(Month) (Day) (Year)
High School Graduate Of_______________________________________________________________________
(School or GED) (State) (Year)
Social Security Number________________________________ Marital Status: Married ______ Single _____
If you choose not to use your Social Security number, a number will be assigned for identification purposes. Financial
Aid cannot be processed without Social Security number.
U.S. Citizen? Yes _____ No _____ If not, Visa Type _____
Permanent Resident___________________________________________________________________________
(County) (State) (Zip)
Parent/Guardian/Spouse__________________________________________Telephone_____________________
Circle One: Mr. Mrs. Ms. Mr & Mrs.
Address_____________________________________________________________________________________
Ethnic/Racial Status (required for federal and state accounting purposes only):
Asian American_____ Black/American_____ Mexican/American_____
American Indian_____ Hispanic/American_____ White_____
Other_____
Have You Earned Previous College Credit? Yes_____ No_____ Hours of Credit______________
College (s) Where Credit Was Earned____________________________________________________________
Did either of your parents graduate from a 4-year institution? Yes_____ No_____
Have You Ever Been Convicted of a Felony? Yes_____ No_____ If yes, please give a brief explanation
(What, where, when): __________________________________________________________________________
Attach your $100.00 non-refundable check/money order payable to Colby Community College to this form. Include this
application in your portfolio along with the other necessary requirements listed on your “checklist”.
I certify that the information given is correct and complete. I understand that submission of false information is grounds for
denial of admission, re-enrollment or immediate suspension if enrolled. If accepted as a student at Colby Community College,
I agree to abide by the rules and regulations of the college regarding conduct, financial and other obligations. By signing this
statement, I also hereby authorize the release of all my college, vocational and/or high school transcripts and other pertinent
records to Colby Community College.
Signature: ________________________________________
Date: ___________________________
Colby Community College does not discriminate on the basis of race, color, gender, age, disability, national origin or ancestry, sexual orientation or religion. For
inquiries, contact the Title IX and ADA Coordinator, Colby Community College, 1255 S. Range Ave., Colby, KS 67701. title9@colbycc.edu. 785.460.5490
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