SIPI Application

Application for Admission

JOO-Admissions/Records
(505) 346-2338

SOUTHWESTERN INDIAN POLYTECHNIC INSTITUTE
"A National Indian Community College"
United States Department of the Interior
Bureau of Indian Education
Mailing Address: P.O. Box 10146; Albuquerque, NM 87184
Physical Address: 9169 Coors Boulevard, N.W.; Albuquerque, NM 87120

Which trimester do you intend to begin taking courses?
□ FALL □ SPRING □ SUMMER YEAR: _____
May-Aug
Jan-April
Sept-Dec

I am applying as a:
□ New Student
□ Readmit Student
□ Transfer Student

□ Concurrent Student (HS)
□ Non-degree Student

Maiden Name / Previous Name

Legal Name (Last, First, Middle)
Legal or Permanent Address (Number, Street, Rt., Box, City, State, Zip Code)

Telephone No.

Commuter Address While Attending SIP! (Number, Street, Rt., Box, City, State, Zip Code)

Commuter Telephone No.

E-mail Address While Attending SIP!

Cell Telephone No.

Sex (Check One)

□ MALE □ FEMALE

)

(

)

(

)

Date ofBirth (Mo., Day, Yr.) U.S. Social Security No.

Place of Birth (City, State)

Are you a member ofa U.S. Federally Recogmzed Tribe?

(

□ YES

□ NO

I[YES, Please provide a copy o[Certificate ofIndian Blood (CIB) with application.

Name ofTribe:

Circle Highest Grade Completed in High School:

7 8 9 10 11 12

Telephone No.

Relationship

Notify in Case ofEmergency (Name, Address)

(

)

Name and Address (City, State) of Last High School Attended:

High School Graduation Date (Mo., Day, Yr.):
Please, orovide a coov ofofficial Hi2.h School transcriot showi112 f!raduation date.

Ifyou have NOT graduated from High School, Have you passed a GED test?

□ YES

□ NO

IfYES, Please provide a GED report o[Tesl results. You must be 18 years of age or older to apPlyfor the GED program.

Have ou attended Colle e? □ YES
□ NO I YES, Please com lete the table below:
FOR TRANSFER AND READMISSION STUDENTS ONLY: List all post-secondary schools, colleges, and universities in
order ofattendance. Transfer students MUST submit an OFFICIAL college transcript.
Address (City, State)
Dates Attended
Credits Earned
Name of School

GENERAL INFORMATION - PLEASE ANSWER ALL QUESTIONS
Are you a U.S. Veteran?
□ YES
□ NO

I[YES, Please provide a copy oflatest DD-214 Form with apPlication.

Are you currently on or pending Criminal Probation or Parole?

I[YES, Please Explain:

Will you require student dormitory housing?

□ YES

□ YES

□ NO

If YES, Housing ApPlication must be completed and submitted with apPlication.

OMB Control No: 1076-0114
Expiration Date: XX/XX/XXXX

□ NO

GENERAL STUDENT BACKGROUND SURVEY - PLEASE ANSWER ALL

UESTIONS

Are you a single parent?
Do you speak your tribal language?
What is your current marital status?
SINGLE
MARRIED
YES
NO
YES
NO
Are you the first generation ofyour family to attend a post-secondary
Do you reside on your tribal reservation?
educational institution?
YES
NO
YES
NO

□
□

□

□

□

□

□

Select the highest level of education for each parent/guardian:
Mother's Education:

D Completed High School Diploma or GED Equivalent
D Completed a Certificate (approximately I-year training)
D Completed an Associate Degree (2-year college degree)
D Completed a Bachelor's Degree (4-year college degree)
D Completed a Graduate Degree

□ Not Applicable

□
□

□

Father's Education:

D Completed High School Diploma or GED Equivalent
D Completed a Certificate (approximately I-year training)
D Completed an Associate Degree (2-year college degree)
D Completed a Bachelor's Degree (4-year college degree)
D Completed a Graduate Degree

□ Not Applicable

Assessment Survey:
What is your current objective in attending SIPI? Please Check the box next to any or all ofthe statements that apply to you.
Meet certification/licensure requirements
Obtain a Certificate

D
D Personal interests
D Explore courses
D Improve skills for present job
D Undecided/unknown

D
D Obtain an Associate Degree
D Transfer to another college or university
D Preparation to change careers
D Self-improvement and/or to improve basic skills
D Preparation to enter the job market

CERTIFICATION:

This verifies that all application information I submitted to Southwestern Indian Polytechnic Institute (SIPI) is complete and true.
Reporting any false application information may be grounds for denying admission or suspension from the institution. I also agree to
abide by all ofthe rules and regulations ofSIPI.

Applicant Signature (sign)

Date

Social Security Number

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 SIPI. I give my consent to emergency
operations, psychiatric treatment, and dental or minor surgery, ifsuch procedures become necessary while the student is in college. I
also approve inoculations and treatment in the field ofpreventive medicine as may be deemed necessary by medical personnel.
Relationship

Parent/Legal Guardian Signature
Address (Number, Street, Rt., Box, City, State, Zip Code)

STUDENTS WITH DISABILITIES

Date

(

)

Telephone No

Southwestern Indian Polytechnic Institute 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 not limited to, sign language
interpreters, note takers, audio recording, tutorial services, priority registration, parking, and classroom modification. Please contact
the Vocational Rehabilitation Counselor by phone at (505) 346-23 I 9, regarding disability. The Counselor can arrange for and
monitor needed services in compliance with the American Disabilities Act.

OMB Control No: 1076-0114
Expiration Date: XX/XX/XXXX

Southwestern Indian Polytechnic Institute
P.O. Box 10146, Albuquerque, NM 87184
1-800-586-SIPI

Physical Examination Form - To be filled out by Physician
1. NAME (LAST, FIRST, MIDDLE)

2. NAME OF SCHOOL

4. OTHER NAMES USED (LAST, FIRST, MIDDLE)

5. DEGREE OF BLOOD

3. REGISTRATION NO.

6. TRIBE

7. TRIBAL ID NO.

8. PERMANENT ADDRESS OF PARENT OR GUARDIAN

9. DATE OF EXAM

10. PLACE OF BIRTH

11. DATE OF BIRTH

15. FATHER'S NAME

16. PLACE OF BIRTH

12. AGE

13. SEX

14. OTHER CLINIC OR SCHOOL ATTENDED

17. MOTHER'S MAIDEN NAME

18. PLACE OF BIRTH

19. SIGNIFICANT FAMILY HISTORY (List tuberculosis, venereal disease, diabetes, epilepsy, trachoma in family. Also if parents not living, indicate cause of death.)

20. SIGNIFICANT PERSONAL HISTORY (List, with dates where possible, history of rheumatic fever, chorea, tuberculosis, asthma, convulsive disorder, diabetes, otitis media, pneumonia,
trachoma, other serious illness or hospitilization and menstrual history.)

21. SIGNIFICANT SOCIAL HISTORY:

MEASUREMENTS AND OTHER FINDINGS
22. HEIGHT

23. WEIGHT

24. BUILD
SLENDER

26. PSYCHOLOGICAL AND PSYCHOMOTOR (Tests used and score.)

OMB Control No: 1076-0114
Expiration Date: XX/XX/XXXX

25. BLOOD PRESSURE (Arm at heart level)
MEDIUM

HEAVY

OBESE

A. Systolic

B. Diastolic

Physical Examination Form - To be filled out by Physician (Continued)
27. CLINICAL EVALUATION (Check each item in the appropriate columm.)
NOT
ITEM
NORMAL
AB-NORMAL EVALUATED

NOTES: (Describe every abnormality in detail. Enter pertinent item letter before each
comment.)

A. HEAD, FACE, NECK AND SCALP
B. NOSE
C. SINUSES
D. MOUTH AND THROAT
E. EARS - GENERAL
F. DRUMS (Perforation)
G. EYES - GENERAL (include examination for Trachoma)
H. OPTHALMOSCOPIC
I. PUPILS AND OCULAR MOTILITY
J. LUNGS AND CHEST
K. HEART AND VASCULAR SYSTEM
L. ABDOMEN AND VISCERA (include hernia)
M. ANUS AND RECTUM
N. ENDOCRINE SYSTEM (include indication of puberty)
O. G-U SYSTEM
P. UPPER EXTREMITIES
Q. FEET AND LOWER EXTREMITIES
R. SPINE, OTHER MUSKULOSKELETAL
S. IDENTIFYING BODY MARKS, SCARS, TATOOS
T. SKIN LYMPHATICS
U. NEUROLOGIC
V. PSYCHIATRIC (specify any known personality
deviation)
28. SUMMARY OF DEFECTS AND DIAGNOSIS (List diagnoses with item letters. Include allergies, especially drug allergies.)

29. RECOMMENDATIONS (Further specialist examinations and follow-up indicated. Specify)

30. SIGNATURE OF EXAMINING PHYSICIAN & NAME OF FACILITY OR CLINIC

OMB Control No: 1076-0114
Expiration Date: XX/XX/XXXX

DATE

Office Use Only

APPLICATION FOR RESIDENTIAL HOUSING
GOLDEN EAGLE LODGE OR FOUR WINDS LODGE
SOUTHWESTERN INDIAN POLYTECHNIC INSTITUTE
9169 COORS BLVD NW
ALBUQUERQUE, NM 87184
Housing & Recreation Office: (505) 346-2371 Director: (505) 346-2327
Golden Eagle Lodge: (505) 346-2354 Four Winds Lodge: (505) 346-2356
Applicants Name:

Admission
Status
Room #
Key #
A1
A2
A5

Status:

Social Security #:
(Last, First, Middle Initial)

Street/P.O. Box:

City:

State:

Phone Number:

Cell:

Zip:

**STUDENTS MUST BE 18 YEARS OLD TO RESIDE IN DORM AND BE ENROLLED IN 12 CREDIT HOURS**
Residential Lodge
Request Period:

Year:

Spring:

Male (Golden Eagle):
Female (Four Winds):
New Student:

Summer:

Fall:

Date of Birth:

Age:

Continuing Student:

Readmit Student:
Last Year Attended SIPI:

EMERGENCY CONTACT INFORMATION
Name:

Relationship:
(Last, First, Middle Initial)

Address:

City:

Home Phone:

State:

Work Phone:

Zip:

MEDICAL INFORMATION
Please list any medical problems and physician prescription medications:

SPECIAL ACCOMMODATIONS:

For Students needing handicap accessible rooms, please contact the Housing & Recreation
Staff, at the number listed above.

ADDITIONAL INFORMATION NEEDED
HAVE YOU EVER BEEN CONVICTED OF ANY FELONY AND/OR CURRENTLY ON PAROLE/PROBATION?

YES

NO

If yes please explain:

THE $275.00 STUDENT HOUSING FEE MUST BE PAID IN THE STUDENT ACCOUNTING OFFICE PRIOR TAKING OCCUPANCY.
***All fees must to be paid by Money Order. (PAYABLE TO BIE/SIPI) NO Cash will be accepted.***
SIPI recognizes alcohol and drug abuse as a potential health, safety, and security problem to the students and the SIPI community. As such,
on June 3, 1991, the SIPI Board of Regents passed Resolution 148 entitled "Zero Tolerance" an alcohol and Illegal Drug Policy. If a student
violates any part of the articles and is found guilty, suspension from the Lodge will occur.

Student Signature:
OMB Control No: 1076-0114
Expiration Date: XX/XX/XXXX

Date:
(OHR REV. 07/10/14)

Transfer Credits

Grades earned in courses taken at other institutions are not included in the calculation of SIPI grade point average.
Official high school and college transcripts submitted to the Admissions Office become the property of the College
and will not be copied, transferred, or returned to the student.
Evaluation of Credit
Before previous coursework can be considered for transfer, admissions must receive official transcripts from all
schools where the coursework was completed. Any student requesting transfer credit must contact his/her academic
advisor, who will review the course(s) for which transfer credit has been requested. If the advisor determines that
the course(s) meet the requirements of the student’s program of study, the advisor will complete a SIPI College
Course Credit Transfer form. The signed form will be routed to the department chairperson, the Vice President of
Academic Programs, and the Admissions Office for final approval.
Transfer Credits
Before a course from another institution will be accepted toward a SIPI certificate or degree, the following
requirements must be satisfied:
• Admissions must receive official transcripts from all schools where coursework was completed.
• The academic advisor will evaluate the transfer credits to determine which transfer credits may be applied
toward the student’s program of study.
• Transfer credits in any degree program of study offered by SIPI must have a letter grade of C or higher,
provided the classes are similar or equivalent to courses offered at SIPI.
• A minimum of 24 residency hours in a core area is required for the award of a certificate or degree.
• Official transcripts submitted to SIPI Admissions and Records become the property of the institution and
will not be transferred or returned to the student.
• Only credits from regionally accredited institutions are transferrable.
• To receive transfer credit for career and technical courses, the student must request a copy of the
transcript(s) from the SIPI's Admissions Office and submit them to the appropriate academic division for
review. An interview and/or demonstration of competence may be required before the decision regarding
credit is made. Demonstration of competence is required for all transfer credit more than 10 years old.
• Remedial courses and upper-division courses, 300 & 400 levels, are not generally transferable.
Quarter System Evaluation
SIPI operates on a trimester academic year. Transfer courses from a post-secondary institution that uses a quarter
system will be recalculated to trimester hours (one quarter hour equals 2/3 (0.66) trimester hour) to determine
acceptability.
Military Credits
Credit for military service is granted to those students who have served in the armed forces. Credit for Physical
Education (1 credit) and Health (2 credits) may be granted, provided the course(s) is/are part of the student’s
program of study. The prospective student must provide a Department of Defense Form 214 (DD Form 214), to the
Director, Admissions and Financial Aid during the application process.

OMB Control No: 1076-0114
Expiration Date: XX/XX/XXXX

Office of Admissions
Southwestern Indian Polytechnic Institute
P.O. Box 10146, 9169 Coors Rd NW
Albuquerque, NM 87184
(505)346-2324

Request for Non-Disclosure of Directory Information
The Southwestern Indian Polytechnic Institute, SIPI Re: Privacy Holds:
“At its discretion Southwestern Indian Polytechnic Institute may provide directory information in accordance
with the provisions of the Family Educational Rights and Privacy Act. Directory information is defined as that
information which would not generally be considered harmful or an invasion of privacy if disclosed. Designated
directory information at University of X includes the following: student name, permanent address, local
address, temporary address, electronic mail address, telephone number, dates of attendance, degrees and
awards received.
Students may withhold directory information by notifying the Registrar in writing; please note that such
withholding requests are binding for all information to all parties other than for educational purposes. Students
should consider all aspects of a directory hold prior to filing such a request. Although the initial request may be
filed at any time, requests for non-disclosure will be honored by the SIPI until removed by the student.”
Please consider very carefully the consequences of any decision by you to withhold any category of directory
information. Such designation will call for SIPI not to release any or all of this directory information; any future
requests for such information from non-institutional persons or organizations will be refused.
SIPI will honor your request to withhold any of the categories listed below but cannot assume responsibility to
contact you for subsequent permission to release them. Regardless of the effect upon you, SIPI assumes no
liability as a result of honoring your instructions that such information be withheld.
Please mark the appropriate boxes and affix your signature below to indicate your disapproval for the
institution to disclose the following directory information:
student name
permanent address
local address
temporary address
electronic mail address

DATE

SEMESTER/QUARTER

telephone number
photo
dates of attendance
degrees and awards received
all directory information listed above

STUDENT NAME

YEAR

STUDENT SIGNATURE

Note: Requests for non-disclosure will be honored by the SIPI for no more than one academic year. Re-authorization to
withhold directory information must be filed annually in the Office of the Registrar within the first two weeks of the fall
semester.

OMB Control No: 1076-0114
Expiration Date: XX/XX/XXXX

Paperwor k Reduction A ct 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 Southwestern Indian Polytechnic Institute. 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 SIPI
Admission, P.O. Box 10146, Albuquerque, NM 87184. 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 A ct 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 Public Law 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 consent of the respondent. The primary
purpose and routine uses of this information is to determine eligibility for postsecondary
educational services of the Southwestern Indian Polytechnic Institute, 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.

OMB Control No: 1076-0114
Expiration Date: XX/XX/XXXX