CBA DORMITORY STUDENT APPLICATION
(To be filled out only if you are applying to stay in the CBA dormitory facilities)

Name of Student

I plan to be a:     Three day student (This student stays in the dorm on Mondays, Tuesdays, and Thursday nights only.)
                            Five day student (This students stays in the dorm Sunday through Thursday nights only.)

Person(s) my parents will allow me to stay with on home weekends or times when I cannot go home as scheduled:

Name  
Address City State Zip Code Phone

Name  
Address City State Zip Code Phone

Yes  No       I plan to have a vehicle at CBA. If yes, I understand that the dorm parents will determine when and if I am       
                                 allowed to drive my vehicle.

Yes No        I understand that if an illness/accident occurs while at CBA that my parents and/or guardians are fully       
                                responsible for the medical costs incurred.

Yes No        I will need the dorm parents' regular assistance in taking medication.

 Yes No        I have adequate health insurance.

Name of Insurance Company
Address City State Zip Code
Health Insurance Policy Number(s)
I am taking the following medications on a regular basis:

You will need the following items while living in the dorm:

Optional items include:

(Phones, televisions, microwaves or other electrical items are not allowed without the consent of the Administration.)