Butler

Enrollment Update / Release To Enroll Form

To update your student information and to request to be released to enroll online, please complete the form below. Before completing and submitting the form, you must have completed an Application for Admission and received an acceptance letter in the mail from Butler. Click here if you need to submit an Application for Admission. If you have questions about your acceptance to Butler, please contact the Admissions Office at 316-322-3255. You will need your MyButlerCC username and password to enroll online. If you have forgotten your MyButlerCC username or password, or need to have your password reset, please contact the Butler Helpdesk at 316-322-3306.

Please allow 2-3 business days for your student information and request to be released to enroll online to be processed. Remember that you must be enrolled in a class before the class begins, so enroll early!

* Required Fields

Planning to Enroll for:

Are you a High School student, an International Student, or are you a Butler Community College athlete?

Yes No

Legal Name: (First Middle Initial Last)

SSN #

Date of Birth (MM/DD/YYYY):

E-Mail Address:

Permanent Address-Street

Apt. #

City:

State:

County:

Zip:

Mobile Telephone:

Home Telephone:

Do you agree to receive text messages from Butler?

Mailing Address (if different than above):

Street:

Apt. #

City:

State:

County:

Zip:

Phone:

GrizzlySafe - Butler Emergency Alert Reporting System

For emergencies and school closings, please enter a mobile (cell) or home telephone number where you can always be reached.

Telephone Number : *

Please be aware you are agreeing to be contacted through our emergency notification system by text and voice mail.

Personal Emergency Contact Information

Name:	Relationship:
Street:	City:	State:	Zip:
Home Phone:	Work Phone:

Residency

Are you a Kansas resident? *

Yes No

If yes, date residency began

Previous College Information

In area provided list any colleges, universities, or vocational-technical schools you may have attended.
(Please include institution name, city, state, country, dates attended, hrs earned and what degree or certificate was earned if any)

	College, University, Vo Tech	City	State	Country	Dates Attended	Hours Earned	Degree/ Cert Earned
1st Institution
2nd Institution
3rd Institution

Note: Transcripts are required for pre-requisite courses.

Additional Information:

Are you a single parent?*

Yes No

Limited English proficiency? *

Yes No

Mother's Highest Level of Education*

Father's Highest Level of Education*

Are you Active Military?*

Yes No

Military Affiliation: *

Do you plan on using veterans educational benefits? Yes No

Per KS state statute (KAR 28-1-30) for prevention & control of TB: * Please indicate "Yes" or "No" as appropriate. Failure to complete as instructed could result in being dropped from classes. College Health will contact students indicating "Yes" or refusal to answer the items below:

You've been outside the U.S. more than 30 days?

If so where?

If so when (Start/End Dates)?

Are you foreign born? If so, where?

If so where?

You have ever been in contact with a person who has been diagnosed with known active Tuberculosis (TB).

Have you recently had any of the following unexplained signs or symptoms: coughing up blood, chest pain, weight loss or loss of appetite, fever or chills, cough (> 3 weeks), fatigue, respiratory difficulty or night sweats?

Would you like to be contacted by the Disability Services Office?*	Yes No	Academic Support? *	Yes No	Are you seeking short-term training leading to work? *	Yes No
Do you follow a Kansas Works (TAA) or Workforce Development (WIA) academic plan?*				Yes No

Academic Information:

What is your Education Goal? *

Where are you planning to transfer the classes taken at Butler?*

What career and/or major are you planning to pursue at the transfer institution? *

What semester and year are you planning to enroll at Butler? *

Sem.

List the specific courses you are planning to take at Butler by term:*

Example:
Summer 2013–English Comp. I
Fall 2013–Public Speaking

* How many hours per week are you working?:

Current Semester Information

As a student at Butler, I take full responsibility for my choices concerning my educational goals. I also understand it is my responsibility to find out how Butler Courses will transfer and if they meet my education goals.

I authorize Butler Community College, all its entities, to correspond with me electronically via my MyButlerCC e-mail account. If I wish to cancel the authorization, I must submit a written request.

Additional Comments/Questions for your advisor:

NOTICE OF NONDISCRIMINATION Applicants for admission and employment, students, parents, employees, sources of referal of applicants for admission and employment and all unions or professional organizations holding negotiated agreements or professional agreements with the institution are hereby notified that this institution does not discriminate on the basis of race, religion, color, national origin, sex age or disability in admission or access to, or treatment of employment in its programs and activities. Any person having inquiries concerning Butler Community College's compliance with the regulations implementing Title VI, Title IX and Americans with Disability Act of 1990 is directed to contact the coordinators who have been designated to coordinate the educational institution's efforts to comply with the regulation implementing these laws.

Specific complaints of alleged discrimination under Title IX (sex) and Section 504 (handicap) should be referred to:

TITLE IX COORDINATOR
Director of First Year Experience
715 E 13th St
Office 5002C
Andover, KS 67002
316.218.6373

SECTION 504 COORDINATOR
Director of Disability Services
Office of Disability Services
901 South Haverhill Road
Hubbard Center, Room 603
El Dorado, KS 67042
316-322-3321 (Local)
316-322-3321 (Wichita Metro)

Title VI, Title IX and Section 504 ADA complaints may also be filed with the Regional Office for Civil Rights.

Address correspondence to:

U.S. Department of Education, Region VII
Office for Civil Rights
8930 Ward Parkway, Suite 2037
Kansas City, MO 64114

Butler

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