Fort Scott Community College Admission/Enrollment Form
All information must be filled in completely.
Semester: ❑ Spring 20____ ❑ Summer 20____ ❑ Fall 20____
Date:_________________________
SOCIAL SECURITY NUMBER: __________________________________ Email:_________________________________________
Name:_______________________________________________________________________________________________________
(Last) (First) (Middle)
Other Name Used:______________________________________ Birthdate:_ __________________________Age:_____ Sex:_____ Address for college mailings.
Permanent Street Address:_ ______________________________ Permanent Telephone Number:_ ___________________________
Permanent City:_ ______________________________________ Permanent State/Zip:_ ___________________________________
Have you lived in Kansas the past 6 months:_________________ Permanent County:______________________________________
Are you Hispanic or Latino: Yes ❑ No ❑ U.S. Citizen: Yes ❑ No ❑
Race: ❑ A-Asian
❑ B-Black or African American
❑ I-American Indian or Alaska Native ❑ U-Race and Ethnicity unknown Are you a Veteran: Yes ❑ No ❑
❑ F - Nonresident Alien
❑ H-Hispanic of any race ❑ P-Native Hawaiian or Other Pacitic Islander ❑ X-Two or more races ❑ W-White
Local Street (Where you live while attending college):_________________________________________________________________
Local City:_ __________________________________________ Local State/Zip:_ _______________________________________
Local Telephone:_______________________________________ Work Telephone:________________________________________
Employer:____________________________________________________________________________________________________
Name of Parent, Guardian or other next of kin:_______________________________________________________________________
Street:_ ______________________________________________ City:_ ________________________________________________
State/Zip:_____________________________________________ Telephone Number:_ ____________________________________
Relationship: _ ______________ (P-Parent, G-Guardian, O-Other) Did either of your parents graduate from a 4-year college? Yes ❑ No ❑
Year graduated or will graduate from high school: ___________ GED completed: Yes ❑ No ❑ Year __________
High School attended:____________________________________________________ High School Diploma? Yes ❑ No ❑
List colleges attended:___________________________________________________________________________________________
Have you taken FSCC classes? Yes ❑ No ❑ Major:________________________________________________
College hours completed at other colleges:_ _________________ Circle: (1-29) (30-63) (64+)
Please check your college objective: ❑ 2-year Associate Degree
❑ 4-year Bachelor’s Degree
❑ 2-year Associate of Applied Science Degree
❑ Certificate
❑ None of the above
Fort Scott Community College does not discriminate on the basis of race, color, national origin, sex, age, religion or disability in admission or access to its programs
Rev. 10/08
and activities. Extension Site_______________________________
Course No.
Course Title
Sem. Hrs.
Schedule
Instructor
Time
Room
Circle Days
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An official transcript from high school and all colleges attended must be on file in registrar’s office prior to enrollment day.
All students are responsible for completing all add/drop forms for any classes added/dropped.
I certify that all the information on this form is true to the best of my knowledge.
Signature:_ __________________________________________________________ Date:_ _______________________
Advisor’s Signature:___________________________________________________ Major:_ ______________________
I hereby certify that this student is enrolled as
a junior or senior in high school and is
recommended for enrollment at Fort Scott
Community College.
For office Use Only
Computer______________
Paid___________________
Tuition
$_ ____________
Receipt No._____________
Reg. Fees
$_ ____________
_____________________________________
Check_________________
Student Center$_ ____________
Cash__________________
Misc.
$_ ____________
_____________________________________ Financial Aid:
Total
Date
Pell ____ GSL ____ Sch. ____
$_ ____________
Signature, High School Principal