Application for Admission to Haskell Indian Nations Univ

APPLICATION FOR ADMISSION

Haskell Indian Nations University

OMB Control No. 1076-0114 Expires: XX/XXXX

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?

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FALL

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SPRING YEAR: SUMMER

Which type of application?

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New Student Readmit Student Transfer Student

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Non-Degree-Seeking Student KS College & University fulltime/Haskell part time

Legal Name (Last, First, Middle)

Preferred First Name

Maiden Name / Previous Name(s)

Off-Campus Address While Attending Haskell

Number/Street		City		County	State	Zip Code
Phone Numbers Permanent Telephone Local Cell ( ) - ( ) - ( ) -					Primary Email Address
Gender Social Security Number: ____-___-_____ REQUIRED. Please print clearly. You must provide your social security number as a part of the application process. Your social security number will not be released to agencies outside of the University and will not be used as your student identification number. You will be assigned a random eleven alpha-numeric 11-digit student identification number when your application is processed. Male Female	Place of Birth (City, State)		Date of Birth (mm/dd/yyyy)		Have you attended Haskell previously? If so what was the last semester/year attended?

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_{Social Security Number – REQUIRED and print clearly} 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 an enrolled member of a federally recognized tribe or at least one-fourth total Indian blood descendant of an enrolled member of a tribe eligible for BIA education benefits? _____ YES _____NO

If YES, please provide official documentation of your status as a member and/or descendant

Are you a member of a U.S. Federally Recognized Tribe? _____YES ____ NO Tribe Name:

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.

Have you taken the ACT/SAT:  YES  NO

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

Date of ACT/SAT Exam(s)

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

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Have you attended any technical schools, colleges, or universities?  YES  NO If YES, Please complete the table below

List, in order of attendance, all technical, post-secondary schools, colleges, and universities attended. All students who have attended other technical schools, colleges, and/or universities MUST submit an OFFICIAL college transcript (Please list if attended college classes while in high school).

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 Mgmt. _____ Environmental Science

_____ Media Communications _____ Social Work _____ Indigenous & American Indian Studies

_____ Health, Sports & Exercise Science

Will you require student residential (on-campus) housing? _____ YES _____ NO

If YES, please download and complete a Housing Application and mail to Haskell Indian Nations University, 155 Indian Avenue, Box 5032, Lawrence, KS 66046. You can also fax this form to the Housing Department at 785-832-6618.

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

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Address (Number, Street, 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 Americans with 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 15 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.