APPLICATION TO CORN BIBLE ACADEMY

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Name Phone Number  
Address City State Zip Code
Birth Date     Age Male Female Social Security Number      

School Currently Attending Is there an IEP from your school?
Current School Address City State   Zip Code
Principal's Name School Phone Number

What grade will you be in when you enter CBA?
I am applying for admission to CBA for the school year.
List your most recent grades in these subjects (estimated grades are acceptable):
 Math Science English History


Which extra-curricular activities would you like to participate in while a student at CBA? (Check all that apply)

Basketball Soccer Choir Hand Bells
Academic Team Newspaper Yearbook Volleyball (Girls)
Football (Boys) Band Drama Pep Band
Softball (Girls) Baseball (Boys)    

Which church do you attend?
Church Address City State Zip Code
How often do you attend church?
 Once a month Once a week Twice a week More than twice a week  I do not attend regularly

Have you accepted Jesus Christ as your personal Savior? Yes  No
If so, when and where?

Write a brief paragraph describing your family.

Please answer the following questions:
 Yes No        Do you use tobacco in any form?
 Yes No        Have you ever experimented with drugs?
 Yes No        Do you use alcohol?
 Yes No        Will CBA need to administer medication to you on a regular basis?
 Yes No        Are you on any kind of medication?
 Yes No        Have you ever been suspended from school? If yes, why?
 

Do you have any physical limitations that CBA should know about?   Yes No     
 If so, what are they?
Please write a brief description of your present relationship with God.

Write a paragraph concerning the reason(s) that you are applying for admission to CBA.

FAMILY INFORMATION

Your Father's Name
Address (if different from yours)  City State Zip Code
Father's Home Phone Father's Work Phone Father's Cell Phone
Your Mother's Name
Address (if different from yours)  City State Zip Code
Mother's Home Phone  Mother's Work Phone  Mother's Cell Phone 
Are your parents:         Married                 Remarried                 Divorced                 Separated

Paternal Grandparent(s) Name
Address City State Zip Code Phone 
 

Maternal Grandparent(s) Name
Address City State Zip Code Phone

Person(s) financially responsible for you to attend CBA:
First Name
Address City State Zip Code Phone 
Amount Committed    Total Amount      1/2 Tuition Amount     Other (List amount you will commit)

Second Name
Address City State Zip Code Phone
Amount Committed    Total Amount      1/2 Tuition Amount    Other (List amount you will commit)

REFERENCES

Please list the name, address, and phone number of four adults who will help determine if CBA is the best educational/spiritual choice for you.

First Reference: (not a relative)

Name   Address
City      State          Zip Code Phone

Second Reference: (relative)

Name   Address
City      State          Zip Code Phone

Third Reference: (church member)

Name   Address
City      State          Zip Code Phone

Fourth Reference: (church member)

Name   Address
City      State          Zip Code Phone

 

Student Agreement:

I have read the Corn Bible Academy "Standard of Conduct Agreement" and agree to abide by these standards while I am associated with the school as a student. I promise to respect those in responsible positions, to honor and comply with the policies and standards of the student handbook, to responsibly assume my obligations academically, and to promote and contribute to the program of CBA as a Christian school.

Parent/Guardian Agreement

I agree to hold the school and its' agents harmless for any liability to my child or any guardian or parent thereof because of any claims on behalf of my child against the school or any agent thereof because of any injury or alleged injury to my child. Should legal action, for any reason, be taken against Corn Bible Academy or any employee or agent thereof on my child's behalf and the school or it's agent not be found at fault, I agree to pay any attorney fees, damages or other costs that Corn Bible Academy or it's agent should incur to defend itself against such action.
 

Student Name Date Submitted Email Address
Parent Name    Date Submitted Email Address