The Christian Institute Registration

Registration Form:

-=Personal Information:=-

Legal Name:

Last Name:
First Name:
Middle Name (complete):
Suffix: ("Jr, etc.")

Gender: M F
Prefer to be called (nickname):
Former last name (if any):

Birthdate: (mm/dd/yyyy)
E-mail Address:

Permanent Home Address:
(Number and Street)
(Apartment / Lot Number)
(City or Town) , (State or Province) (Zip / Postal Code)

If different from above, please give your mailing address for all admission and regular correspondence:
Mailing Address: (from / to / )
(Number and Street or Post Office Box Number)
(Apartment / Lot Number)
(City or Town) (State or Province) (Zip / Postal Code)

Phone at mailing address:
Permanent Home Phone:
Cell Phone:

-=Citizenship:=-

Citizenship:
a U.S. Citizen
a Dual U.S. Citizen: please specify other country of citizenship
Foreign Citizen
Country of foreign citizenship Alien Registration Number
If you are not a U.S. Citizen and live in the United States, how long have you been in this country?

Optional information (voluntary):
Place of birth: (City or Town) , (State or Province) (Country)
First language, if other than English:
Language spoken at home:

-=Tests and Test Scores:=-

TEST INFORMATION
The Christian Institute requires that all students be satisfactorially enrolled in secondary school or higher and registered to take or have passed at least one CLEP(tm) exam
(or equivalent) prior to enrollment. Students who wish to enroll full-time with The Christian Institute must also take either the ACT or SAT exam and submit the results to The Christian Institute.
CLEP Date scheduled or taken Grade: Passed/Failed

CLEP Date scheduled or taken Grade: Passed/Failed

Alternate Test: Test or course name: Date taken/scheduled to be taken: Grade:

ACT Date taken/to be taken English Score Math Score Reading Score Science Score Composite Score
SAT I Date taken/to be taken Verbal Score Math Score
SAT II Date taken/to be taken Verbal Score Math Score
Test of English as a second language (TOEFL or other exam) Test Date taken/to be taken Score
"*Please have all scores for CLEP™, ACT, SAT I, SAT II, TOEFL, DANTES, AP, any completed college courses, or other exams taken forwarded to The Christian Institute immediately."

-= Application Information =-

Are you applying as:
an early/ dual enrollment student
a normal Freshman
a college transfer student?

Your current academic level is:
Secondary (Jr. High/High School)
College Freshman
College Sophomore
College Junior
College Senior
College Graduate
Post-Graduate

Are you applying for one of the following non-degree options?
CEU (Continuing Education Units)
Biblical Worldview Certificate only

Do you currently
Homeschool?
attend a Christian school?
attend a Private / Parochial school?
attend government school?

Other

When do you wish to begin taking courses?
Immediately
Within 30 days
Within months
By MM/DD/YYYY

-=Family Information=-

Parent 1:

First Name: Middle Name: Last Name:
Suffix: Living: Yes No
Date Deceased:
Home Address:
Home City: State: Zip:
Occupation: Name of Business or Organization:
College (If Any): Degree and Year Attained:
Professional or Graduate School (If Any): Degree or Certificate and Year Attained:

Parent 2:

First Name: Middle Name: Last Name:
Suffix: Living: Yes No
Date Deceased:
Home Address:
Home City: State: Zip:
Occupation: Name of Business or Organization:
College (If Any): Degree and Year Attained:
Professional or Graduate School (If Any): Degree or Certificate and Year Attained:

Other Information:
If not with both parents, with whom do you make your permanent home?:
If married, spouse's name:
Please Select if Parents are: If Divorced, Month/Year of Divorce:

Brothers/Sisters:
Please give names of all brothers and sisters. If they have attended college, give the names of the institutions attended, degrees, and approximate dates:

-=Extracurricular, Personal, and Volunteer Activities=-
Please list your principal extracurricular, community, and family activities and hobbies in the order of their interest to you. Include specific events and major accomplishments such as musical instrument played, varsity letters earned, position attained, event participated in, etc. Check any activities you hope to pursue during college to allow us to focus on the highlights of your activities.

Activity 1
Activity:
Grade Level: 9th 10th 11th 12th Post-Secondary
Approximate Time (In Hours) Spent A Week: A Year:
Check If You Plan To Do During College

Activity 2
Activity:
Grade Level: 9th 10th 11th 12th Post-Secondary
Approximate Time (In Hours) Spent A Week: A Year:
Check If You Plan To Do During College

Activity 3
Activity:
Grade Level: 9th 10th 11th 12th Post-Secondary
Approximate Time (In Hours) Spent A Week: A Year:
Check If You Plan To Do During College

Activity 4
Activity:
Grade Level: 9th 10th 11th 12th Post-Secondary
Approximate Time (In Hours) Spent A Week: A Year:
Check If You Plan To Do During College

ACADEMIC HONORS
Briefly list or describe any scholastic distinctions or honors you have won beginning in year that you commenced ninth grade study:

WORK EXPERIENCE
List any job (including summer employment) you have held during the past three years, specific nature of the work, employer, approximate dates of employment, and approximate number of hours worked per week.

SHORT ANSWER
Please describe which of the activities (extracurricular and personal activities or work experience) has been most meaningful to you.

PERSONAL PROFILE (up to 300 words; use a personal word processing program like Word or Word Perfect and cut and paste it here)
"This personal profile helps us to learn who you are in ways differently from courses, grades, test scores, and other objective data. We want to know you personally. Please tell us about yourself including what you like and dislike, about your family, your hobbies, interests, and your worldview. "

PERSONAL STATEMENT (up to 500 words; use a personal word processing program like Word or Word Perfect and cut and paste it here)
"This personal statement also helps us become acquainted with you in ways differently from courses, grades, test scores, and other objective data. It will demonstrate your ability to organize your thoughts and express yourself. We are looking for an essay that further will help us know you better as a person and a student. Please write an essay (250 - 500 words) on three of the topics of your choice from the options listed below. Please indicate your topics by checking the appropriate boxes below (remember to please choose three)."
1 Describe your family situation and how your parents/guardians have influenced your life and who you are.
2 Share the three most significant events of your life.
3 Share a profound religious experience you have had and how it impacted you.
4 Evaluate a significant achievement, risk you have taken, or ethical dilemma you have faced and its impact on you.
5 Discuss some issue of personal, local, national, or international concern and its importance to you.
6 Indicate a person who has had a significant influence on you, and describe that influence.
7 A range of academic interests, personal perspectives, and life experiences adds much to the educational mix. Given your personal background, describe an experience that illustrates what you would bring to The Christian Institute community as a student or an encounter that demonstrates the importance of the value of your individuality to the mission of the college.
8 Other topic of your choice (title it here ).

REQUIRED SIGNATURE
Your typed "signature " is required.
"I certify that all information in my application, including any Personal Profile and Personal Statement, is my own work, factually true, and honestly presented."

Signature Date

This college is committed to administer all educational policies and activities without discrimination on the basis or race, color, religion, national or ethical origin, age, handicap, or gender.
The admission process at private undergraduate institutions is exempt from federal regulations implementing Title IX of the Education Amendments of 1972.