Haskell Application for Admission

OMB Control No. 1076-0114
Expires: 11/2018

APPLICATION FOR ADMISSION
Haskell Indian Nations University
Mailing Address: 155 Indian Ave. Box 5031, Lawrence, KS 66046
Physical Address: 112A Navarre Hall, Lawrence, KS 66046

In which semester do you intend to begin taking
courses?
 FALL
 SPRING
YEAR: ________
✔ SUMMER


Which type of application?
 New Student  Readmit Student  Transfer Student
 Non-Degree-Seeking Student  KS College & University fulltime/Haskell part time

Legal Name (Last, First, Middle)

Preferred First Name

Maiden Name / Previous Name(s)

City

County

State

Zip Code

Off-Campus Address While Attending Haskell:
Number/Street
City

County

State

Zip Code

Legal or Permanent Address:
Number/Street

Phone Numbers:
Permanent Telephone

(

)

Gender
 Male

Primary Email Address
Local

-

(

Cell

)

-

(

Place of Birth (City, State)

)

-

Date of Birth (mm/dd/yyyy)

 Female

Social Security Number – REQUIRED and print clearly

Have you attended Haskell previously? If
so what was the last semester/year
attended?

You must provide your social security number as part of the application process. Your social security
number will not be released to agencies outside of the university and it will not be used as your student
identification number. You will be assigned a random eleven alpha-numeric digit student identification
number when we process your application.

Are you a member of a U.S. Federally Recognized Tribe?
 YES
 NO
Tribe Name:
If YES, please provide official documentation of your status as a member.
Notify in Case of Emergency (Name, Address, City, State)

Relationship
Telephone

Note: If you would like this person or other designated person(s) to have access to Admissions or Registrar related information, you will need
to complete a FERPA Release of Information form which can be found on the Admissions webpage on Haskell’s website at www.haskell.edu
Have you ever been adjudicated guilty or convicted of a misdemeanor, felony, or other crime?  YES
 NO
If YES, please explain on a separate sheet of paper the dates, place, offense, and the outcome.
High School Graduation Date (mm/dd/yyyy)
Name and Address (City, State) of Last High School Attended:
Please, provide a copy of your official High School transcript showing graduation date.

Have you taken the ACT/SAT:

 YES

 NO

Date of ACT/SAT Exam(s)

If you have taken the ACT/SAT, please have your official scores sent to Haskell Indian Nations University
School Code: 010438; ACT Haskell Code: 1415; SAT Haskell Code: 0919

If you have NOT graduated from high school, have you passed a GED test?
 YES
 NO Date of GED Exam(s)
If YES, Please provide a GED report of test results.
Have you attended any technical schools, colleges, or universities?  YES  NO If YES, Please complete the table below:
List all technical, post-secondary schools, colleges, and universities in order of attendance. All students who have attended other technical
schools, colleges, and/or universities MUST submit an OFFICIAL college transcript.
Name of College or University
Address (City, State)
Dates Attended
Credits Earned

______________________
______________________
______________________
______________________

____________________
____________________
____________________
____________________

_____________________
_____________________
_____________________
_____________________

_________
_________
_________
_________

What major are you interested in pursuing? (NOTE: You must have a minimum of 45 college credits to be admitted into a bachelor degree program.)
Associate Degree (2-year) Majors:
Baccalaureate Degree (4-year) Majors:
 Communication Studies
 Natural Science
 Business Administration
 Community Health
 Para-Professional Education
 Elementary Education
 Liberal Arts
 Recreation & Fitness Management
 Environmental Science
 Media Communication
 Social Work
 Indigenous & American Indian Studies
Will you require student residential (on-campus)
 NO
housing?  YES

What is your current marital status?
 SINGLE
 MARRIED  SEPARATED  DIVORCED

 WIDOWED

CERTIFICATION:
This verifies that all application information I submitted to Haskell Indian Nations University is complete and true. Reporting any false
application information or withholding any prior academic work may be grounds for denying admission or suspension from the university. I also
agree to abide by all of the rules and regulations of Haskell Indian Nations University.

Applicant Signature (sign)

Print Name Clearly

Date

FOR PARENT/GUARDIAN OF A MINOR APPLICANT UNDER 18 YEARS OF AGE:
I am legally responsible for this applicant and hereby apply for his/her admission to Haskell Indian Nations University.

Parent/Legal Guardian Signature

Relationship

Date

(
Address (Number, Street, Rt., Box, City, State, Zip Code)

)
Telephone No

STUDENTS WITH DISABILITIES
Haskell Indian Nations University ensures access to facilities and academic programs for students identified by the American Disabilities Act.
Accommodations are determined on an individual basis and include, but are not limited to, note takers, audio recording, tutorial services,
parking, and classroom modification. Please contact the Disability Support Services by phone at (785) 749-8470 regarding disability. The
Coordinator can arrange for and monitor needed services in compliance with the Americans with Disabilities Act.

Applications will not be processed until all required materials are received by the Office of Admissions.
Faxed applications (including supporting documents) will NOT be accepted.
Paperwork Reduction Act and Public Burden Statement:
Authority: Paperwork Reduction Act of 1995, Public Law 96-511, as amended.
This information is collected from Native American and Alaska Native individuals seeking enrollment to Haskell Indian Nation University. The information is used
to identify students, determine eligibility, and identify any health and counseling services needed, and safety issues related to dormitory situations and record
keeping purposes. The completed admissions forms are electronically entered into Haskell Indian Nations University Admissions and Records system to identify
and maintain current information on students. It is estimated that this form will take an average of 30 minutes to complete. An agency may not conduct or sponsor,
and a person is not required to respond to, a collection of information unless it displays a valid OMB Control Number. Comments concerning clarity, utility of
information or burden reduction may be sent to Attn: Information Collection Clearance Officer – Indian Affairs, 1849 C Street, NW, MS-4141, Washington, DC
20240. Please note: comments, names, and addresses of commentators are available for public review during regular business hours. If you wish us to withhold this
information you must state this prominently at the beginning of your comment. We will honor your request to the extent allowable by law.
Privacy Act Statement:
Authority: Privacy Act of 1974, Public Law 93-579, as amended.
This information collection document contains information that is covered under the Privacy Act and is for students completing Federal records and forms that
solicit personal information. The Bureau of Indian Education will not disclose any record containing such information without the written consent of the respondent
unless the requestor uses the information to perform assigned duties. The primary purpose and routine uses of this information is to determine eligibility for
postsecondary educational services of the Haskell Indian Nations University, for identification purposes, to render appropriate services for students and for record
keeping purposes. Examples of others who may request the information in summary are Members of Congress, or the Office of Management and Budget for the
purpose of the budget. Collection of your Social Security Number is for identification purposes and is voluntary. Your voluntary responses are treated in a highly
confidential manner.
EFFECTS OF NONDISCLOSURE: Providing this information is voluntary. If you choose not to provide information it may affect your eligibility for educational
services.

Revised 09/08/2016