Iowa Central Admissions Application

To fill out an application to take a Distance Education (FlexNet) course please click here for the Distance Education Application.

* indicates a required field

Personal Information
Enter your name as it appears on your Social Security Card
*
First Name (legal name):
A value is required.
 
Nickname:
 
Middle Name/Initial:
*
Last Name (surname):
A value is required.
 
Maiden Name:
 
SSN:
Invalid format. Musat be in 123-45-7890 format.
*
Birth Date (MM/DD/YYYY):
A value is required.Invalid format. Must be in MM/DD/YYYY format.
*
Sex:
Please select an item.
*
Address:
A value is required.
 
P.O. Box:
*
City:
A value is required.
 
County:
*
State:
A value is required.
*
Zip Code:
A value is required.
 
Home Phone:
You must enter a home or cell phone number.Invalid format. Must be in (123) 456-7890 format.
 
Cell Phone:
You must enter a home or cell phone number.Invalid format. Must be in (123) 456-7890 format.
 
I would like to receive text messages about upcoming events at Iowa Central:
 
Cell Phone Carrier:
A value is required.
*
E-Mail:
(enter only 1 e-mail address)
A value is required.Invalid format.
 
Iowa Resident:
 
Date of Residency:
 
Are you a US Citizen:
If you answered no:
  * Country of Birth: A value is required.
  * Country of Citizenship: A value is required.
  Type of Visa: A value is required.
 
Is English your native language?
Ethnicity: (check all that apply)
 
Hispanic/Latino
White
Native Hawaiian or other Pacific Islander
Black or African-American
Asian
American Indian/Alaskan Native
Other Ethnic Group
Prefer not to Respond

Emergency Contact Information
 
Contact:
 
Other:
*
Name:
A value is required.
*
Phone:
A value is required.Invalid format. Must be in (123) 456-7890 format.

Admissions Information
*
What Center do you plan to attend? Please select an item.
*
Term: Please select an item.
 
Status Entry:
 
How long do you plan to attend Iowa Central:
 
Did either of your natural born or adoptive parents (with whom you were living before your 18th birthday) complete a bachelor's degree?
The above information is requested to determine your eligibility for federally-funded assistance programs and will NOT be used in determining admission.

Program Major Information
Select ONE program that you are planning to major in: Please select an item.
Please check the extra-curricular activities that interest you:
Dance Line
Music-Instrumental
Music-Vocal
Newspaper (Collegian)
Cheerleading (Co-Ed)
Student Ambassador
Student Government
Theatre
   
Men's Intercollegiate Athletics:
Baseball
Basketball
Bowling
Cross Country
Football
Golf
Marching Band
Rodeo
Soccer
Sports Shooting
Track and Field
Wrestling
   
Women's Intercollegiate Athletics:
Basketball
Bowling
Cross Country
Golf
Marching Band
Rodeo
Softball
Soccer
Sports Shooting
Track and Field
Volleyball

High School Information
*
Name of High School Last Attended:
A value is required.
*
Graduation Year:
A value is required.
*
City:
A value is required.
*
State:
A value is required.
 
Are you currently attending High School:
 
If not a high school graduate, have you earned the GED:
 
Date GED Earned:
 
Where GED Earned:

College Attendance Information

List all colleges and universities including Iowa Central, that you have previously attended. Remember to contact each college and request an official transcript be sent to:

Student Records
Iowa Central Community College
One Triton Circle
Fort Dodge, Iowa, 50501

College Name
City, State, ZIP
From (mo/yr)
To (mo/yr)

Housing Information
Do you wish to receive a residence hall app:

You must check the box to the left in order to submit the form.
By checking this box I certify that the above statements are true and correct to the best of my knowledge. I agree to abide by all approved policies as outlined in the current issue of the college catalog. I agree to report all changes, including name and address, to the Admissions Office.