(To be filled out only if you are applying to stay in the CBA dorm facilities)

Please print and mail the completed form to:
Corn Bible Academy
P.O. Box 38, 208 North Reimer
Corn, Oklahoma 73024

CBA DORM STUDENT APPLICATION

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 student stays in the dorm Sunday through Thursday nights only.)

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

Name _______________________________________________

Address _______________________________________________________________________

City _____________________________ State ______________ Zip Code _________________

Phone _____ - _________________

Name ________________________________________________

Address _______________________________________________________________________

City _____________________________ State ______________ Zip Code _________________

Phone ____ - __________________

___ I plan to have a vehicle at CBA. I understand that the dorm parents will determine when and if I am allowed to drive my vehicle.

___ I will not have a vehicle at CBA.

___ I understand that if an illness/accident occurs while at CBA, my parents and/or guardians are fully responsible for the medical costs incurred.

___ I will need the dorm parents' regular assistance in taking medication.

___ I will not need any assistance from the dorm parents to take medications.

___ I have adequate health insurance.

Name of Insurance Company_______________________________________________________

Address _______________________________________________________________________

City ___________________________ State __________________ Zip Code ________________

Health Insurance Policy Number(s) __________________________________________________

I take the following medications on a regular basis _____________________________________
_______________________________________________________________________________

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

• Bedding
• Pillow
• Towels
• Lamp
• Personal Items

Optional Items include

• Music system (Ipod, CD player, etc.)
• Computer
• Music (Christian only, please)
• Pictures/Posters