2018 CBC College Send Off Registration Form

Community Baptist Church of Englewood

224 First Street

Englewood, NJ 07631

Phone: 201-568-6369 Fax: 201-568-3512 www.cbcofe.org

Reverend Dr. Lester W. Taylor, Jr., Senior Pastor

CBC Educational Council

2022 College Send-Off Registration

SEND-OFF - Sunday, August 7, 2022

You must be a CBC Member for at least two years to apply.

Please complete and submit your application no later than Sunday, July 17, 2022. For more information, contact: cbceduscholarships@cbcofe.org.

Student Name: *

First Name Last Name

Student Address: *

Street Address

Street Address Line 2

City State

Zip Code

Student Cell Phone # *

You will be contacted via text messages

Student Email Address

Gender *

Male Female

College Attending or Planning to Attend in Fall 2022 *

Living on Campus: *

Yes No

Anticipated Date of College Graduation: *

College Level - Fall, 2022 *

Freshman Returning Student (Sophomore-Senior)

CBC Member: *

Yes No

Parent/Guardian Name: *

First Name Last Name

Parent/Guardian Telephone #: *

Parent/Guardian Email Address: