STUDENT APPLICATION

(Please include all siblings)

*Additional questions in this section will be located at the end of this application.

I, the undersigned, do hereby state that on the date indicated, I do grant full and complete permission to SMBC, its employees, or designate, or any related or consulting physician, to render or give emergency medical aid, care, treatment, or assistance that could or would be deemed required or necessary. I also state that should extended or required hospitalization be necessary, I grant full and complete permission for such care and treatment. This consent I give freely and voluntarily, fully knowing and understanding all of the above and its relation to and effect upon me.

For the following conditions/symptoms, please select either "past, current or never"

NOTE: Background Checks will be conducted on all applicants.

Statute 20, United States code,section 1232G and regulations adopted pursuant thereto, here after, referred to as the code, requires that each student be notified of the rights according to him or her by the code. The following is provided as basic general information relative to the code. The code provided for the institution to establish a category of student information termed “directories information “. When available in college records, any information falling in the category of “directories information” will be available to all persons on request, i.e., the IRS, FBI or other government agencies, and for use in SMBC publications, SMBC has identified the following as “directories information “. Students name, address, telephone listing, race, medical history, place and date of birth, major field of study,church membership, denominational affiliation, dates of attendance, degrees and awards received, most recent previous educational agency, and institution attended. 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 college that have responsibility for working with the student. Such information will not be released to second parties without consent of the student except as required for use by the president in the discharge of his official responsibilities as prescribed bylaws, regulations of the state board, and board policies. The designated custodian of such records may release information from his records to others only upon authorization in writing from the student or upon a subpoena by a court of competent jurisdiction.

To obtain consumer reports for employment/volunteer purposes. In considering you for Ministry of Helps or employment and, if you are employed, in considering you for subsequent promotion, assignment, reassignment, retention, or discipline, The River of Tri-Cities Church and Smoky Mountain Bible College, may request and rely upon one or more consumer reports or investigative consumer reports about you that we can obtain from a consumer reporting agency, such as IntelliCorp Records, Inc. In this disclosure, employment refers to volunteer work. For explanation purposes: *A “consumer report” is a written, oral or other communication of any information by consumer reporting agency bearing on your credit worthiness, credit standing,credit capacity, character, general reputation, personal characteristics, or mode of living which is used or expected to be used or collected in whole or in part for the purpose of servicing as a factor in making an employment related decision about you. Such information may include, for example, credit information, criminal history reports, or driving records; and *an“investigative consumer report” is a consumer report and which information on your character, general reputation, personal, or mode of living is obtained through personal interviews with your prior employers, neighbors, friends, or associates, or with others who may have knowledge concerning any such items of information. In the event an investigative consumer report is requested about you, you are entitled to additional disclosures regarding the nature and scope of the investigation requested, as well as a written summary of your rights under the Fair Credit Reporting Act (FCRA”). Under the FCRA, before the company can obtain a consumer report or investigative consumer report about you for employment purposes, we must have your written authorization. Before we take adverse action on the basis, in whole or in part, of information in the report,you will be provided a copy of that report, the name, address, and telephone number of the consumer reporting agency, and a summary of your rights under the FCRA.

I indicate by my signature and hereby certify that the above information is true to the best of my knowledge.I understand that to deliberately falsify information will result in my immediate expulsion from Smoky Mountain Bible College. I indicate by my signature of the medical and health information provided herein is accurate to the best of my knowledge. I understand that all information is maintained as confidential. I indicate by my signature that any evaluation submitted by references are confidential and all statements made will be submitted to Smoky Mountain Bible College with the understanding that its contents will not be shared with me. I hereby waive my right to see the confidential statement submitted in the evaluation forms. I indicate by my signature that I have been notified of my rights as recorded by Statute 20, United States code,section 1232g. I indicate by my signature that I have been notified The River of Tri-Cities Church reserves the right to all intellectual and creative properties created by me during any activities I engaged in at Smoky Mountain Bible College