When do you plan to enter LCC? Fall 20________ Spring 20________ Summer 20________ LCC ID # or SSN________________________________
Legal Name _____________________________________________________________________________________________________________________________
LAST FIRST MIDDLE MAIDEN OR OTHER
Permanent
Address________________________________________________________________________________________________________________________________
STREET CITY STATE ZIP CODE COUNTY
Phone ______________________________ Cell Phone ______________________________ E-mail Address _______________________________________________
_______________________________________________________________________________________________________________________________________
NAME OF HIGH SCHOOL CITY STATE GRADUATION DATE (MO/YR)
Have you traveled/lived outside the United States for at least 3 months? Yes _____ No _____
If yes, please provide dates & countries. ______________________________________________________________________________________________________
Do you grant permission to Labette Community College to release your college grade(s) to your high school? Yes _____ No _____
Labette Community College has permission to use my directory information, student identification photograph, and future photographs for the purpose of
institutional research, student verification, and/or marketing. Yes _____ No_____ (If unchecked the college assumes permission is given.)
I certify that all the information I have provided on this application is complete and correct to the best of my knowledge. I also understand that there are minimum
assessment and program standards that I must adhere to in order to be accepted and remain in the concurrent/dual credit program at LCC. Failure on my part to
maintain minimum performance standards and comply with College program requirements may result in my dismissal from LCC.
Student Signature_________________________________________________________________________________ Date________________________________
As a parent of this child:
I understand my child is enrolling as a student at Labette Community College and will receive college credit. The course(s) my child is enrolled in, will be listed on a
Labette Community College transcript as well as the grade my child earns for the course(s).
I understand I am responsible for tuition, fees and books not covered by any scholarship my child may be eligible to receive. Fees are not covered by scholarships.
Parent Signature ________________________________________________________________________________ Date ______________________________
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I certify that the above named student is enrolled as at least a high school sophomore, or is certified as “gifted” with an IEP (copy must be attached) that specifies
college study, and has permission to enroll at Labette Community College for college credit during the 20_____- 20_____ academic year.
I understand that failure by the student to comply with College and program requirements may result in student dismissal from the concurrent/dual credit program.
____________________________________________________________________________ ______________________________________________________
High School Principal Signature Date
H.S. Counselor Signature ______________________________________ LCC Major __________________________________________ H.S. GPA __________
Labette Community College does not discriminate on the basis of race, color, religion, national origin, sex, age, or qualified handicapped in its education programs,
activities, recruitment, admissions, or employment as required by Titles VI, VII, IX, and section 504 of the Rehabilitation Act of 1973. Inquiries should be directed to:
Vice President of Student Affairs, Labette Community College, 200 South 14th Street, Parsons, KS 67357. Telephone (620) 421-6700 extension 1264.
