New UNDERGRADUATE-GRADUATE ADMISSION APPLICATION

Campus

Entrance Level

Student Classification

Personal Data:

First Name

Last Name

Middle Name

SSN

Street

City

State/Province

Zip/Postcode

Home Phone

Work Phone

Email

Birth Date

Gender

Marital Status

Ethnic Origin:

US Citizen?

Are you a member of a Federally Recognized Tribe?

Yes No Not Selected

Tribe/Agency Location

Ethnicity

Emergency Contact Information:

Contact Name

Cell Phone

Relationship

Are you a first generation student?

Yes No Not Selected
(Do your parents have a four year college degree?)

Have you attended a Head Start Program?

Yes No Not Selected

Do you require services for a disability?

Yes No Not Selected

Are you a veteran

Yes No Not Selected

Are you eligible for Veteran's Benefits?

Yes No Not Selected

Educational Data:

Do you have a High School Diploma?

Yes No Not Selected

Graduation Date

Have you taken the ACT?

Yes No Not Selected

School Attended

Public High School on reservation

Public High School off reservation

BIA School

Tribal or Contract School

Other High School

List school attended

Do you have a GED?

Yes No Not Selected

Date of completion

List all colleges/universities attended:

Colleges/Universities attended: Name 1

Location

Date of attendance

Degree Earned

Colleges/Universities attended: Name 2

Location

Date of attendance

Degree Earned

Colleges/Universities attended: Name 3

Location

Date of attendance

Degree Earned

Are any of these credits being transferred to Sinte Gleska University?

Yes No Not Selected
If yes, please request an official transcript from each institution.

Major

(All students must declare a major, please indicate one only)

Have you received your Associate of Arts degree?

Yes No Not Selected

AA Program

If No

BA Program

If Yes

Please complete the following:

Is English your Primary Language?

Yes No Not Selected

Do you speak Lakota?

Yes No Not Selected

Limited speaker

Yes No Not Selected

Conversational speaker?

Yes No Not Selected

Fluent speaker?

Yes No Not Selected

Other languages?

Family Data:

Mother's Full Name

Is your mother enrolled in a Federally recognized tribe?

Yes No Not Selected

Which Tribe?

If Yes

Father's Full Name

Is your father enrolled in a Federally recognized tribe?

Yes No Not Selected

Which Tribe?

If Yes

Resident Status:

Do you reside on or near a reservation? (Within 60 miles)

Yes No Not Selected

List tribal community

Are you a resident of South Dakota?

Yes No Not Selected

If not, which state

Employment Status

To the best of my knowledge, the information provided on this application is true and correct.

Signed

Date

Ihanktonwan Community College

REGISTRAR’S OFFICE

PO BOX 295

Marty, SOUTH DAKOTA 57361

605-384-3997

www.iccoyate.com

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