Iowa Central Distance Learning Admissions 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.
 
Are you or a family member a veteran?
  * Relationship: Please select an item.
 
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
*
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
*
Is it your goal to receive a degree or diploma from Iowa Central? Please select an item.
*
Select ONE program that you are planning to major in: Please select an item.

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.

Non-Discrimination Statement
It is the policy of Iowa Central Community College not to discriminate on the basis of race, color, national origin, sex, disability, age (employment), sexual orientation, gender identity, creed, religion, and actual or potential parental, family or marital status in its programs, activities, or employment practices as required by the Iowa Code §§ 216.6 and 216.9, Titles VI and VII of the Civil Rights Act of 1964 (42 U.S.C. §§ 2000d and 2000e), the Equal Pay Act of 1973 (29 U.S.C. § 206, et seq.), Title IX (Educational Amendments, 20 U.S.C. §§ 1681 – 1688), Section 504 (Rehabilitation Act of 1973, 29 U.S.C. § 794),  Age Discrimination Act of 1975 (34 CFR Part 110), and Title II of the Americans with Disabilities Act (42 U.S.C. § 12101, et seq.).

If you have questions or complaints related to compliance with this policy, please contact Kim Whitmore, Director of Human Resources, phone number 515-574-1138, whitmore@iowacentral.edu; or the Director of the Office for Civil Rights, U.S. Department of Education, Citigroup Center, 500 W. Madison, Suite 1475, Chicago, IL 60661, phone number 312-730-1560, fax 312-730-1576.