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Student Application

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

Full Name _____________________________________________________________________

Address ______________________________________________________________________
City _______________________________ State ___________ Zip Code __________________
Phone Number _________________________________________________________________

Birthdate _______________ 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 subject areas (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 ____ Yearbook ____ Handbells ____ Band
___ Academic Team ___ Volleyball (Girls) ___ Football (Guys) ___ Drama
___ Pep Band ___ Softball (Girls) ___ Baseball (Guys)

Which church do you attend?
______________________________________________________________________________
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.
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? Yes ___ No ___ 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:

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 Christan school.

Parent/Guardian Agreement:

___ I agree to hold the school and its' agents harmless for any liability to my child of 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 _______________

Student Signature _______________________________________________________________
Email Address __________________________________________________________________

Parent Name ______________________________________ Date Submitted _______________

Parent Signature ________________________________________________________________
Email Address __________________________________________________________________

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Home | General Information | Admissions | Athletics | Fine Arts | Giving Opportunities | Contact Us

208 N. Reimer Street, P.O. Box 38, Corn, Oklahoma 73024 • 580.343.2262 • info@cornbible.org