CSOM Student Application

STUDENT APPLICATION
An Affiliate Campus of West Virginia Christian University

Please print or type. Answer all questions. Applicant must sign and date application before it can be processed.

Do not leave blanks, use N/A if the question does not apply.
Name

First Name Middle Name Last Name
Address

Address

Street Address Line 2

City State

Zip Code
E mail
example@example.com
Cell Phone Number
Date Of Birth

Month Day Year
Date
Social Security Number
US Citizen? (Y/N)
Occupation
Church/ Denominational Background
Present Church
Pastor's Name and Phone Number
Emergency Contact
Relationship to Emergency contact
Phone Number of Emergency Contact
Do you use any of the following? Check all that apply.

Tobacco Alcohol Recreational drugs
Are you sexually active with anyone you are not married to?
Have you ever been arrested, or convicted of a crime? If SO, why?
Gender

Male Female
Race

Caucasian Black Asian Hispanic Jewish Pacific Islander Other
Centerbranch School of Ministry does not discriminate on the basis of nationality, ethnic origin, age, or natural gender. We guarantee the rights and privileges, and the availability of programs and activities to all students of the University.

Privacy Rights of Students Statue 20, United States Code x1232g and regulations adopted pursuant thereto,

Hereinafter referred to as the Code, requires that each student be notified of the rights accorded him or her by the Code.The

following is provided as basic general information relative to the Code:

The Cod e provides for an institution to establish a category of student information termed "directory information". When available in

college records, any information falling in the category of "directory information" will be available to all persons on request (i.e. the IRS, FBI, or other government agencies and for use in WVCU publications WVCU has identified the following student data as "directory information:

1 Name 2 address 3 telephone listing 4 Race 5 Date & Place of Birth

6 Major field of Study

7 Church Membership 8 Denominational Affiliation

10 Degrees & Awards Received

11 Most Recent Previous Educational institution attended
STUDENT APPLICATION
2. NON-DISCRIMINATION POLICY - CONTINUED

All other information, such as health and medical records, disciplinary records, records of personal counseling, required student and family financial income records, transcripts or student permanent academic records, student placement records and other personally identifiable information shall be open for inspection only to the student and such members of the professional staff of the colleges as have responsibility for working with the student. Such information will not be released to second parties without consent

Except as required for use by the president in the discharge of his official responsibilities as prescribed by laws, regulations of the state board, and board policies, the designated custodian of such records may release information from these records to others only upon authorization in writing from the student or upon a subpoena by a court of competent jurisdiction.

Name of Institution, City and State

Did You Graduate? Diploma/ GED?

FINAL TRANSCRIPTS MUST BE SUBMITTED AND COPIES OF HIGH SCHOOL DIPLOMA, IF THERE ARE NO COLLEGE CREDITS SUBMITTED.

Educational History

	Name of Institution	City and State	Start + End Dates	Diploma/GED?	Major?
High School
College
College
College

SPIRITUAL HISTORY
Briefly tell the story of how you came to know Christ
Have you Committed your life to Christ and put your trust in him?

Yes No
Have you received the baptism of the Holy Spirit with the evidence of speaking in tongues?

Yes No
Personal Journey

Don't feel pressure if you are still exploring your goals, just let us know.
What are your educational goals?
What are your spiritual growth goals?
What are your personal growth goals?
What are your ministry goals?
PLEASE READ THE FOLLOWING AFFIDAVIT CAREFULLY BEFORE SIGNING

| certify that | have truthfully and accurately answered all questions contained in this application. I understand that falsification of any kind is grounds for refusal of my application or expulsion should falsehood be discovered after acceptance to the university

2. | indicate by my signature that | have been notified of my rights as recorded by Statute 20, United States Code x1232g
Signature

Clear
Date

Month Day Year
Date
Should be Empty:

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STUDENT APPLICATION

STUDENT APPLICATION

SPIRITUAL HISTORY

Personal Journey