Barton County Community College

Inquiry Form

*Required Fields

Date (mm-dd-yy)

Last name*

First name*

Middle name*

Social Security Number

Current Address*

City*

State*

Zip Code*

County

Telephone No.* (111-111-1111)

E-mail address*(If you don't have an e-mail address, please type "none" in the text field.)

Male* or Female* Birthdate* (mm-dd-yr)

I am presently a high school Sophomore Junior Senior Other

High School*

Year of high school graduation*

Major Area of Study*

I am interested in: (Check all that apply)	Athletic Trainer
Academic Club	Baseball
Band	Basketball - Men's
Campus Christian Fellowship	Basketball - Women's
Cougarettes	Cheerleading
Debate	Cross Country - Men
Forensics	Cross Country - Women
Hispanic Leadership Organization	Danceline
Honors Program	Golf - Men
Meats Judging Team	Golf - Women
Multicultural Student Organization	Soccer - Men
Newspaper	Soccer - Women
Student Ambassador	Softball
Student Government	Tennis - Men
Theatre Arts	Tennis - Women
Vocal	Track - Men
	Track - Women
Other	Volleyball - Women

For more information you can write or call:

Admissions Office
245 NE 30th Road
Great Bend, KS 67530
(620) 792-9241 or 1-800-722-6842
FAX: (620) 786-1160
Email: desemok@bartonccc.edu