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					  WHAT                                   Admission & Scholarship
                                              Application
    drives
   YOU?
                            1. There is no application fee.                5. Students entering college for the first
                                                                              time, pursuing a certificate or degree,
                            2. Complete the Admissions                              or enrolling in a class requiring
                               application. Answer all                                   test scores must have ACT,
                               questions. Do not                                            SAT, Accuplacer or ASSET
                               leave any questions                                            scores on file with
                               blank. NOTE: If you                                             Barton. These scores
                               are an international                                            are used for placement
                               applicant, please                                               in English, Reading, and
                               visit our website for                                           Math courses. Students
                               International student                                          without test scores
                               information and                                             must take the Accuplacer
                               application.                                             or ASSET test. (Fort Riley
                               www.bartonccc.edu/                                  students may submit or take the
                               prospective/typeoflearner/international        Compass test). Barton’s assessment
                                                                              is free of charge. Contact the Testing
                            3. All degree/certificate seeking students
                                                                              Center at (620) 792-9344 or 800-748-
                               must have official post-graduation
                                                                              7594 for a testing schedule or further
                               transcripts (high school, home school,
                                                                              information.
                               or proof of GED) from each institution
                               attended sent by the granting               6. To be considered for the Barton
                               institution directly to Barton. Home           Academic Scholarship Award,
                               school credit evaluations may be               complete the application section
                               submitted in lieu of a transcript or           inside this form. This scholarship
                               diploma from the school administrator.         application deadline is March 15
                               NOTE: Student will be admitted as a            for the following academic year.
                               “Special Student” until all transcripts
                               from previously attended institutions are   7. Anyone seeking an accommodation
                               received and evaluated.                        under provisions of the Americans
                                                                              with Disabilities Act should notify
                            4. If you are applying to the following           Student Support Services by calling
                               areas of study, you may need to meet           (620) 792-9240 or e-mailing
                               additional admissions requirements.            studentsupport@bartonccc.edu.
                               Contact or visit the respective area for
                               more information.                           8. Return this application to the address
                               http://programs.bartonccc.edu                  listed below.

                                 • Medical Laboratory Technician              Barton Community College
                                                                              Admissions Office
                                 • Medical Assistant                          245 NE 30 RD
                                 • Nursing                                    Great Bend, KS 67530
                                 • Paramedic (MICT)




(620) 792-9286 OR 800-722-6842               FAX: (620) 786 -1160                                GoBarton.com
                                                                                                                    PROGRAMS OF STUDY
                                                                                  DEGREE CODES
                                                                                                                                                                                                     Career Technical Education Programs                                 Transfer Programs
 AA             Associate in Art                                            NDS             Non-Degree Seeking and not eligible for federal aid                                                      C and/or AAS                                                        AS, AA, and/or AGS
 AGS            Associate in General Studies                                SAPP            Stand Alone Program
                                                                                                                                                                                                     Career technical education offers students                          Transfer programs are
 AS             Associate in Science                                        *               Emphasis of Study                                                                                        the option of one or two-year programs                              designed to prepare you for
                                                                                                                                                                                                     designed to provide knowledge and skills,                           transferring from Barton to a
 AAS            Associate in Applied Science                                +               May be eligible for federal aid under correlating degree program
                                                                                                                                                                                                     which will prepare them for employment�                             four-year college or university�
 C              Certificate Program                                         ++              Not eligible for federal aid

CAREER TECHNICAL EDUCATION PROGRAMS                                                                         TRANSFER PROGRAMS (Liberal Studies)                                                                         TRANSFER PROGRAMS (continued)
Accounting - Technical Specialist (AAS) � � � � � � � � � � � � � � � � � � � �                   5210      Accounting (AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 5201        Horticulture/Turf Management (AS) � � � � � � � � � � � � � � � � � � � � � � � 0216
Administrative Assistant* � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �         5205      Agribusiness (AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 0108        Journalism (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 0901
Adult Health Care                                                                                           Agricultural Economics (AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 0110                Law (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 2200
   Activity Director (NDS) ++ � � � � � � � � � � � � � � � � � � � � � � � � � � � �             5119      Agricultural Education (AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 0111              Law Enforcement (AS) * � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 4310
   Certified Medication Aide (SAPP) ++ � � � � � � � � � � � � � � � � � � �                      5126      Agriculture Communications (AS) � � � � � � � � � � � � � � � � � � � � � � � � � 0109                      Liberal Studies (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 2402
   Certified Nurse Aide (SAPP) ++ � � � � � � � � � � � � � � � � � � � � � � � �                 5120      Agriculture Transfer Option (AS) � � � � � � � � � � � � � � � � � � � � � � � � � � 0100                   Management (AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 5224
   Home Health Aide (SAPP) ++ � � � � � � � � � � � � � � � � � � � � � � � � � �                 5121      Agronomy (AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 0210        Marketing (AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 5220
   Rehabilitation Aide (SAPP) ++ � � � � � � � � � � � � � � � � � � � � � � � � �                5122      Animal Science (AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 0211          Math Education (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 1307
Agriculture Business Management (AAS) � � � � � � � � � � � � � � � � � � �                       0106      Anthropology Cultural Studies (AA, AS) � � � � � � � � � � � � � � � � � � � � 4504                         Mathematics (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 2701
   Crop or Livestock Production*                                                                            Architectural Engineering (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � 1403                     Medical Laboratory Technician (AS) � � � � � � � � � � � � � � � � � � � � � � � � 5110
Automotive Technology (AAS, C) � � � � � � � � � � � � � � � � � � � � � � � � � �                4706      Architecture (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 4801          Medical Technology (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 2604
Business Administrative Technology (AAS) � � � � � � � � � � � � � � � � � �                      5205      Art (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 5001   Medicine (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 2602
   Administrative Assistant*                                                                                Art Education (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 1309           Military Studies (AGS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 4507
Business Management and Leadership (AAS) � � � � � � � � � � � � � � �                            5217      Athletic Training (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 2610             Milling Science (AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 0214
Business Technology (AAS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �           5225      Automotive Technology (AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 4707                   Modern Languages (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 1601
Computer Networking Specialist (AAS, C) � � � � � � � � � � � � � � � � � �                       5215      Biology (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 2630       Mortuary Science (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 2605
Corrections (AAS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �   4306      Business (AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 5200      Music (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 5004
Criminal Justice (AAS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �      4302      Business Computer Management (AS) ++ � � � � � � � � � � � � � � � � � � 5212                               Music Education (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 1305
Crop Protection (AAS, C) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �        0104      Chemistry (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 4001         Nursing – ADN (AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 5117
Dietary Manager (C) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �       2004      Chiropractic (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 2601          Nursing Transfer (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 2622
Early Childhood (AAS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �       2003      Computer Information Systems (AS) � � � � � � � � � � � � � � � � � � � � � � � 5213                        Occupational Therapy (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � 2623
Emergency Management/Homeland Security (AAS, C) � � � � � � �                                     4508      Computer Science (AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 1101              Optometry (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 2606
Emergency Services Education                                                                                Criminal Justice (AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 4301          Park Management and Conservation (AS) � � � � � � � � � � � � � � � � � � 0215
   Emergency Medical Services Administration (AAS) � � � � � � � �                                1508      Cytotechnology (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 2617              Pharmacy (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 2607
   Emergency Medical Technician - Basic (SAPP) + � � � � � � � � � �                              5107      Dance (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 5010       Philosophy (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 3801
   Emergency Medical Technician - Intermediate (SAPP) ++ � �                                      5114      Dental Hygiene (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 2611              Photography (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 5005
   First Responder (SAPP) ++ � � � � � � � � � � � � � � � � � � � � � � � � � � � �              5113      Dentistry (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 2603         Physical Education (Coaching/Recreation) (AA, AS) � � � � � � � � � � 1303
   Mobile Intensive Care Technician (AAS) � � � � � � � � � � � � � � � � � �                     5109      Dietary Management (AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 2006                Physical Sciences (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 4000
Fire Science Technology (AAS) � � � � � � � � � � � � � � � � � � � � � � � � � � � �             4303      Dietetics (AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 2005     Physical Therapy (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 2608
   Contact the EMS Office at (620) 792-9341 for details                                                     Drama (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 5002       Physical Therapy Assistant (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � 2613
Graphic Design Multimedia Specialist (AAS) � � � � � � � � � � � � � � � �                        5216      Early Childhood Education (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � 1304                     Physicians Assistant (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 2614
Hazardous Materials Management (AAS, C) � � � � � � � � � � � � � � � � �                         1505      Economics (AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 5206       Physics (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 4003
Manufacturing Skills Certificate (SAPP) ++ � � � � � � � � � � � � � � � �                        1507      Elementary Education (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � 1301                    Political Science (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 4502
Medical Administrative Technology (AAS) � � � � � � � � � � � � � � � � � �                       5209      Engineering (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 1401           Pre-Nursing (AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 2621
Medical Assistant (AAS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �         5222      Engineering Technology (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � 1402                    Psychology (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 4201
Medical Coding (C) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �      5227      English (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 2301       Public Administration (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � 4505
Medical Laboratory Technician (AAS) � � � � � � � � � � � � � � � � � � � � � �                   5110      Environmental Compliance Concentration (AS) � � � � � � � � � � � � � � 1506                                Radiology Tech (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 2615
Medical Transcriptionist (C) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �          5223      Exercise Science (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 2618              Religion (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 3802
Military Technology (C) ++ � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �            2901      Finance (AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 5211     Respiratory Therapy (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 2609
Natural Gas Transmission & Distribution Technician (AAS, C) � � �                                 4606      Food Science (AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 0212        Secondary Education (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � 1302
Nursing                                                                                                     Forensic Science (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 4311              Social Work (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 4506
   IV Therapy (SAPP) ++ � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �           5125      Forestry (AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 0201    Sociology (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 4503
   Practical Nursing - PN (C) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �         5116      General Studies (AGS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 2401            Special Education (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 1306
   Associate Degree Nursing – ADN (AAS) � � � � � � � � � � � � � � � � � �                       5117      Geology (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 4002         Speech Communication (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � 2302
   Students passing the state exams become a                                                                Golf Course Management (AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � 0213                    Sports Administration (AA, AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � 1308
   Licensed Practical Nurse or a Registered Nurse                                                           Graphic Design (AA) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 5003          Veterinary Medicine (AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 2625
Pension Administration* (SAPP) ++ � � � � � � � � � � � � � � � � � � � � � �                     5208      Health Information Management (AA, AS) � � � � � � � � � � � � � � � � � 2612                               Wildlife Science (AS) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 2616
Phlebotomy Training (SAPP) + � � � � � � � � � � � � � � � � � � � � � � � � � � � �              5111      History (AA) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 4501
Tech Accounting Specialist (AAS) � � � � � � � � � � � � � � � � � � � � � � � � � �              5210

Non-Discrimination Notice: To provide equal employment, advancement and learning opportunities to all individuals, employment and student admission decisions at Barton will be based on merit, qualifications, and abilities� Barton County Community
College does not discriminate on the basis of any characteristic protected by law in all aspects of employment and admission in its education programs or activities� Any person having inquiries concerning Barton County Community College’s non-
discrimination compliance policy, including the application of Equal Opportunity Employment, Titles IV, VI, VII, IX, Section 504 and the implementing regulations, is directed to contact the College’s Compliance Officer, Barton County Community College,
Room A-123, Great Bend, Kansas 67530 (620) 792-9234� Any person may also contact the Director, Office of Civil Rights, U�S� Department of Education, Washington, DC 20201�
PERSONAL INFORMATION:
*Social Security Number _______ - _______ - _______ (Your social security number will not be used as your assigned college ID number.)
When do you plan to enroll? ❑ Fall (Aug-Dec)            ❑ Spring (Jan-May)          ❑ Summer (May-July)           Year 20 ______
*Complete Legal Name ___________________________________________________________________________________________________
                                             Last                          First                        Middle                  Previous or Maiden Name

*Address _______________________________________________________________________________________________________________
                                  Legal address                                            City                              State            Zip

*Phone Number: __________________ Cell Phone Number: __________________ *E-Mail address: __________________________________

*Sex: ❏ Male ❏ Female             Date of Birth: ________________________________
                                                            Month/Day/Year

Emergency Contact Information: _________________________________________ ____________________________ ____________________
                                                            Name                                  Relationship to Student                    Phone

Do either of your biological or adoptive parents have a bachelor’s degree? ❏ Yes          ❏ No

Are you a member of the military family?          ❏ Dependent       ❏ Active Duty        ❏ Other          ❏ No

ETHNICITY (Data used for reporting purposes only)
Are you Hispanic or Latino? ❏ Yes       ❏ No
What is your Race? (Check all categories of race that best describes you.)
  ❏ American Indian or Alaskan Native            ❏ Asian           ❏ Black or African American             ❏ Hispanic or Latino
  ❏ Native Hawaiian or Pacific Islander          ❏ White

*RESIDENCY STATUS:
NOTE: Your residency status will not affect your admission to the College. It is used only to determine your tuition based on state and federal laws. For
additional residency information, visit http://bartonccc.edu/prospective
Are you a U.S. citizen? ❏ Yes ❏ No If no, please provide Alien Registration Number ______________________________________________
                        *Citizenship is used to determine tuition rate. Students must provide alien resident card or refer to “Non U.S. Citizens”
                        procedures in the Kansas residency statement and request an affidavit if applicable.
If yes, are you a Kansas resident? ❏ Yes ❏ No                       Date Kansas Residency Began: _________________________________________
                                                                                                                 Month/Day/Year

Legal County of Residence: ___________________________              Date County Residency Began: _________________________________________
                                                                                                                 Month/Day/Year

*HIGH SCHOOL INFORMATION:
NOTE: All degree seeking students must have official post-graduation transcripts (high school, home school, or proof of GED) sent by the granting
institution directly to Barton. Home school credit evaluations may be submitted in lieu of a transcript or diploma from the school administrator.
❏ High School Graduate          ❏ GED Graduate           ❏ Home School Graduate             ❏ Non-H.S./Non-GED Student
________________________________________________________________________________________________________________________
High School/Home School/GED Center                                       City                                  State                           Zip

High School/Home School Graduation Date: _______________________________                    GED Certificate: __________________________________
                                                            Month/Year                                                      Month/Year of Completion



                        BARTON ACADEMIC SCHOLARSHIP AWARD APPLICATION
 Application deadline is March 15 for the following academic year.
 The Academic Scholarship Award will be awarded to graduates of Kansas high schools or other Kansas residents who received their
 GED from a center in Kansas based on the highest of the following criteria: Grade Point Average, ACT composite score, or GED score.
 Cumulative High School GPA: _____ based on 4.0 scale              or GED Score (if applicable): ______
 ACT Scores: Composite: ______             English: ______         Math: ______           Reading: ______           Science: ______
 Disclaimer: We must have an official high school transcript, ACT test scores, or GED test scores to award the final award.
 Student Athletes: Jayhawk Conference rules state that students receiving an athletic books and tuition scholarship must meet a 3.5 GPA criteria
 upon high school graduation and are eligible for only one academic scholarship in the amount of no more than $500 a semester or $1,000 a year.

*Information will be used for both Admission and Scholarship purposes.
PREVIOUS COLLEGE(S):                               NOTE: All degree seeking students must have official post-graduation transcripts (high school,
                                                   home school, or proof of GED) from each institution attended sent by the granting institution
                                                   directly to Barton.
List in order all colleges attended.
 Name                                                           City                            State                     Dates Attended




ENROLLMENT INFORMATION:
Student Type: Check one only
❏ First Time Freshman           ❏ Continuing/Former Barton Student               ❏ Transfer to Barton         ❏ Other ______________________
                                                                                                                               Please Specify
Are you seeking a certificate and/or degree from Barton Community College?
❏ Certificate         ❏ Degree            ❏ Both           ❏ Neither

PROGRAM(S) OF STUDY (Academic Interests):                                     ___________________________________________________

INTERESTS:
Are you interested in participating in any of the following activities:
❏ Academic Club                               ❏   Hispanic Leadership Organization        ❏   Athletic Trainer             ❏   Soccer - Men
  (Area of Interest:_______________)          ❏   Honors Program                          ❏   Baseball                     ❏   Soccer - Women




                                                                                                                                                    Detach along the fold line
❏ Band                                        ❏   Multi-Cultural Society                  ❏   Basketball - Men             ❏   Softball
❏ Campus Christian Fellowship                 ❏   Newspaper                               ❏   Basketball - Women           ❏   Tennis - Men
❏ Cheer Squad                                 ❏   Student Ambassador                      ❏   Cross Country - Men          ❏   Tennis - Women
❏ Community Student Organization              ❏   Student Government                      ❏   Cross Country - Women        ❏   Track - Men
❏ Dance Team                                  ❏   Theatre Arts                            ❏   Golf - Men                   ❏   Track - Women
❏ Debate                                      ❏   Vocal                                   ❏   Golf - Women                 ❏   Volleyball - Women
❏ Forensics
❏ Other: _______________________


I certify that the information given is correct and complete. I understand that submission of false information and/or failure to
submit supporting documents is grounds for denial of admission, re-enrollment or immediate suspension if enrolled. If accepted
as a student at Barton Community College, I agree to abide by the rules and regulations of the college regarding conduct, financial,
and other obligations.

STUDENT SIGNATURE:                      _________________________________________________________               DATE:      ___________________

				
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