2017 - 2018 complete application all pages -...

ChristianLifeCollege Page1 9023WestLane|Stockton,CA|95210

ApplicationInstructionsandProcedure:ReadCarefullyandexecuteasinstructed.

Admissiontothecollegeisbaseduponacarefulevaluationofeachindividual’sapplicationfile,includingsupportingdocuments.Theapplicationandallsupportingdocumentsmustbereceivedbeforeanadmissiondecisioncanbedetermined.Registrationforclasses,dormroomassignment,andarrivaloncampusislimitedtothosewhohavebeengrantedapprovalforadmission,includingreceiptofdownpayment.Toensureconfidentially,alldocumentscontainedintheapplicant’sfilearethepropertyofthecollegeandwillnotbereturnedorreproducedfortheapplicantorotherinterestedpersonsUponreceiptofthecompletedapplicationandallsupportingdocuments,theapplicantwillbenotifiedwithinfour(4)weeksoftheenrollmentdecisionoftheAdmissionsCommittee.Thecollegereservestherighttorequireapersonalinterviewbeforeafinaldecisionisreached.APPLICATIONSUBMISSIONDEADLINES:

FallSemester August1stofthesamesemesteryear.

SpringSemester November30thoftheprevioussemesteryear

EnrollmentRequirement

AdmissiontoChristianLifeCollegerequiressuccessfulcompletionofhighschoolorequivalent.TheminimumrequiredGPAis2.0.AGPAof1.99to1.7maybeadmittedonaprovisionalbasis,only.(AcademicProbation,restrictionsapply)APPLICATIONPROCESSThecompletedapplicationmustbeaccompaniedbyanon-refundableapplicationfee,a500wordstatementofpurpose,SAT/ACTofficialtestscore,medicalformwithphysiciansignature,pastoralendorsement,twopersonalreferenceletters,officialtranscript(s),andcurrentprofessionalphoto.PhotocopiesarenotacceptableREVIEW,CHECKWHENCOMPLETE,ANDSUBMITALLAPPLICATIONDOCUMENTS.NUMBERS1-10AREREQUIREDDOCUMENTS.

q 1.APPLICATIONcomplete*theattachedapplicationforadmission.(includingsignatures)*Pleasenote:Incompleteapplicationdocumentswillnotbeprocessed.

q 2.APPLICATIONFEE$30makepaymentonlineatwww.clc.edu-

q 3.STATEMENTOFPURPOSESubmitanessayofminimally500words,astatementofthecurrentstatusofcallandcommitmenttoChristianeducationandministry.Thestatementshouldinclude:conversionexperience,familybackground,yourspiritualdevelopment,yourcalltoministry,includingspiritualandeducationalgoals.Thisessaymustbesubmittedindigitallyexecutedtextfiles.(.doc,.docx,.pages,.pdf,etc.)Handwrittenisnotacceptable.

q 4-6.REFERENCELETTERS(sendenclosedreferenceformsandletterrequesttoyourpastorandpersonsofchoice.)o ONE(1)PastoralEndorsementLetter.ThelettermustbecompletedbytheapplicantsSeniorPastor.This

lettershouldreferencethenatureoftheapplicant’sChristiancharacterandcommitmenttoministry.Endorsementshouldbeexecutedonchurchletterhead,attachedtotheenclosedPastoralReferenceform.

o TWO(2)GeneralReferenceletters.Bothlettersarerequiredfrompersonsotherthanrelativeswhohave

knowntheapplicant,personally,foratleasttwoyears.Referencelettershouldaccompanytheenclosed,completedGeneralReferenceform.

q 7.OFFICIALTRANSCRIPT(S)(requestformsenclosedforyourconvenience)Applicantsmustrequestanofficialtranscriptfromhis/herhighschoolorcollege.OfficialTranscriptsarerequired,mustbemailedfromtheoriginatingInstitution,andaccompaniedbytheofficialInstitutionsealoranofficialstamp.Photocopiesofthetranscriptsarenotacceptable.

ApplicationINSTRUCTIONS AND CHECKLIST

[email protected]

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2017-2018


q 8.SATORACTAcompleteapplicationrequiresthattestresultsaresubmittedduringtheapplicationprocess.

q 9.HEALTH,IMMUNIZATIONANDINSURANCEFORM(formenclosed)On-CampusapplicantsarerequiredtocompletetheMedicalInformationdocumentprovidedintheapplicationpackage.Medicalformsincludedetailedinstructionsforcompletion,includingarequiredsignaturefromapplicant’sphysician.Disclosingspecificmedicalconditionsordisabilitiesunderthe“MedicalDisclosures”portionoftheformisoptionalandnotarequirementofenrollmentorhousing.Anyinformationdisclosedontheformiskeptstrictlyconfidential.Pleaseincludecopiesofimmunizationcardordocumentationandhealthinsurancecard.

q 10.PHOTOSubmitacurrentprofessionalself-portrait.Photocopiesarenotacceptable.

q 11.CONSENT&AUTHORIZATIONFORM–Formincludedintheapplicationpacket.Pleasereturnafullyexecuted,initialedandsigned,originaldocument.

q 12.VEHICLEREGISTRATIONFORM(optional)CompleteandsubmitvehicleformONLYifyouplantobringavehicleoncampus.

Mailalldocumentsto:ChristianLifeCollegeOfficeofAdmissions9023WestLaneStockton,CA95210


APPLICANTCarefullyreadthefollowingandifinagreementsignanddateasindicated

IfreelyandwillinglyenterintothisconsentandauthorizationcovenantagreementwithChristianLifeCollege(CLC).IunderstandthatCLCisacommunityofApostolicPentecostalbelieverswhohavejoinedtogetherforthepurposeofBiblicalstudy,academicadvancement,ministerialtraining,personaldevelopmentandspiritualgrowth.InconsiderationofmyenrollmentasastudentatCLCIcovenantandagreeasfollows:

1. IunderstandthatitisnotthepurposeofCLCfacultyandstafftoserveasmyparentsorasapoliceforceandthatatrustmustexistbetweenmeandCLCwithrespecttomyconductandbehavior._____initial.

2. WhileastudentatCLC,IcovenantandagreetoconductmyselfbothonandoffcampusinamannerconsistentwithanApostolicPentecostalChristian._____initial.

3. IagreetoabidebytheprovisionsandrequirementscontainedintheCLCStudentHandbookandtoabidebythedirectionsoftheCLCfacultyandstaff._____initial.

4. IunderstandandagreethatCLChastherightatanytimetosuspendorterminatemyCLCenrollmentorparticipationinactivitiessponsoredorsanctionedbyCLCforanyofthefollowing:(1)myfailuretobehaveoractinaccordancewiththeStudentHandbook,(2)myfailuretorespectfullyfollowtheinstructionsofCLCfacultyandstaff,or(3)foranyconductdeemedbyCLCfacultyorstafftobeincompatiblewiththeinterestsorharmonyofthereligiousandeducationalpurposesofCLC.Ifmyenrollmentorparticipationinanysuchactivityisterminated,Iunderstandthatanypaymentmadeforanyenrollmentand/oractivitymaynotberefundedandthatIwillcontinuetoberesponsibleforanyoutstandingbalancesdueonmyaccountwithCLC._____initial.

5. IamawareofthevariousactivitiessponsoredorsanctionedbyCLCincludingministerial,educational,residential,social,andrecreationalactivities.Iamalsoawareofthepotentialhazardsandriskstomeandtomypersonalpropertyinconnectionwithmyparticipationinsuchactivities,includingtherisksassociatedwithactivityrelatedtravel.Ivoluntarilydesiretoparticipateinsuchactivitiesand,subjecttoanyavailableinsurancecoverage,andonlywithrespecttoCLCanditsfacultyandstaff,Ivoluntarilyassumeallrisksassociatedwithsuchactivities.Further,IunderstandandagreethatneitherCLCnoritsfacultyorstaffshallberesponsibleforanydamage,lossortheftofanypersonalproperty(includinganymotorvehicleormusicalinstrument)belongingtomeorinmypossessionwhethersuchdamage,lossortheftoccursonthepremisesofCLCornot._____initial.

6. Iamphysicallyfitandcurrentlyhavenoknownphysical,emotional,ormentalconditionthatwouldimpairmyabilitytoparticipateincourseworkorotherCLCsponsoredorsanctionedactivities.IagreetopromptlynotifyCLCfacultyandstaffofanychangeinmyabilitytoparticipateinanysuchcourseworkoractivity._____initial.

7. IunderstandandagreethatCLCdoesnotprovidehealthinsurancecoverageformeandthatifIdesirehealthinsurancecoverage,Iamresponsibleforobtainingandforthecostofanysuchinsurance._____initial.

8. Iagreeto,authorizeandapprovetheuseofanyaudio,visualandotherrecordeddepictionofmyname,likenessandvoicecapturedortakenduringanyCLCsponsoredorsanctionedactivity(includingclasses,classprojects,services,conferences,tours,performancesandrecordings)forthepurposesofpromotion,sale,fundraising,oranyotheruseinfurtheranceofCLC’sreligiousandeducationalpurposes._____initial.

Applicant/StudentCONSENT &

AUTHORIZATION

[email protected]



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9. Finally,Iconsent,authorizeandreleaseCLCfacultyandstafftodisclosetoanddiscusswiththeindividualslistedbelowthefollowing:

a. (1)informationconcerningmyacademicperformance,includingclassattendanceandgradesreceived,_____initial.

b. (2)informationconcerningmyspiritualdevelopment,includinganybehaviorthatmayreflectonmyspiritualdevelopment,mymoralcharacterandconduct,andmyfitnessforChristianministry,and_____initial.

c. (3)financialinformationinCLC’spossessionpertainingtome,includingthepaymentordelinquencyofbalancesdueonmyaccountwithCLC._____initial.

AnysuchdisclosureanddiscussionmaybemadeatthediscretionofCLCfacultyandstafftothefollowing:(1)myparent(s),(2)myPastor,(3)theofficialsofanychurchorministryatwhichIseektoministerorteachand(4)theofficialsofanyreligiousorganizationtowhichIapplyforministeriallicenseorthroughwhichmyministeriallicensemaybemaintained._____initial

IhavecarefullyreadthisConsent&Authorizationandunderstandandagreetoitscontents.Icovenantandagreetowholeheartedlyapplymyselftomycoursework,personaldevelopmentandspiritualgrowth,andtoconductmyselfatalltimesinamannerbefittinganApostolicPentecostalChristian.Applicant’sSignature______________________________________Date____|____|_______PrintedName_____________________________________________


Pleaseprintclearly.

ApplicationTerm:Beginning:qFall20____qSpring20____ChooseCampusStudentorOnlineStudent: qCLCCampus qCLCOnlineWhoorwhatinfluencedyoutoapplyforadmissiontoChristianLifeCollege:(checkallthatapplyandsupplydetailsinthefinalsectionofthisapplication.)qParent qPastor qFriend qAlumni qConferenceqInternetqSOSTourRepresentative qXperienceqPersonalCampusTourAPPLICANT’SPERSONALINFORMATIONSECTIONName______________________________/___________________________/____________ Last First Middle

Dateofbirth:_____/_____/_____Gender:qMaleqFemaleMaritalstatus:qSingleqMarriedSocialSecurityNumber:_______/_______/_______ Age:_______StreetAddress:_______________________________________________________Apt.#___________City:_______________________________State:____________________________Zip:____________Phone:Home(___)-____-______Cell(___)-____-______Email:_________________________________

Ethnicity/Race:2partquestion(informationisoptional) Part1. qHispanic qNon-Hispanic

Part2. qAsian/PacificIslanderqBlack/Non-HispanicqHispanic qAmericanIndian/NativeqWhite

YourCitizenshipCountry:___________________________ U.S.PermanentResidence:qYesqNo

HaveyouattendedCLC?qYesqNo Ifso,whatyear?__________

Areyoutransferringfromanothercollege/university? qYesqNoAreyoutransferringcredits,ifpossible? qYesqNoDesiredDegree:qAssociateqBachelor Residence:qOn-CampusqOff-CampusMajorProgram:qBibleandTheology qGeneralMinistry* qBusinessAdministration

*GeneralMinistryEmphasis:qMissiologyqMediaqMusic

Admissions APPLICATION

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FINANCIALINFORMATION

NAMEOFPERSONresponsibleforschoolbill:__________________________/____________________ Last First

RelationshiptoStudent: qSelf-Pay qParent qPastor qOther:______________

Employment: qYes,Iwillneedtofindjob qNo,Iwillnotneedajob qIwillbetransferringfrommycurrentjobNOTE:ADownPaymentisrequiredbyallnewandreturningstudents:(chooseanoption,below)

qFullTime/On-CampusStudent– DownPaymentminimum$2550–DUE10dayspriortoarrivalqFullorPartTime/OFF-CampusStudent–DownPaymentminimum1/3oftotaltuitionandfees–basedonnumberofcredits/units–DUEatregistration.qOnlineSchoolStudent–DownPaymentminimum1/3oftotaltuitionandfees–basedonnumberofcredits/units–DUEatregistration.

FAMILYANDEMERGENCYINFORMATION

Father/Guardian:__________________________/_______________________/__________ Last First MiddleInitial

Phone:Home(___)-____-______Cell(___)-____-______StreetAddress:_______________________________________________________Apt.#___________City:_______________________________State:____________________________Zip:____________

Mother/Guardian:__________________________/_______________________/__________ Last First MiddleInitial

Phone:Home(___)-____-______Cell(___)-____-______StreetAddress:_______________________________________________________Apt.#___________City:_______________________________State:____________________________Zip:____________

EMERGENCYINFORMATION Towhomshouldemergencycallsorcorrespondencebedirected?

Name:_____________________________________Relationship(ifotherthanparent):__________________________________________________________Phone:Home(___)-____-______Cell(___)-____-______EmailAddress:_______________________________________________________


PASTORINFORMATION(thecollegewillrequestarecommendationfromyourseniorpastor)SeniorPastor:____________________________________/___________________________________ Last First

ChurchName:________________________________________________________________________ChurchAffiliation:___________________________________________________StreetAddress:_______________________________________________________Apt.#___________City:_______________________________State:____________________________Zip:____________Phone:Home(___)-____-______Cell(___)-____-______Church(___)-____-______PastorEmailAddress:_______________________________________________________

CHURCHINFORMATION (APPLICANTQUESTIONS)

Howlonghaveyouattended:Years:_____

1. HaveyoubeenbaptizedinthenameofJesus? qYesqNoDate:___________

2. HaveyoureceivedtheHolyGhostasinActs2:4? qYesqNoDate:___________

3. Describeanychurchresponsibilitiesand/orleadershiprolesheld:

________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. Listanyinstrumentsthatyouplayinchurch:

________________________________________________________________________________________________________________________________________________________________________________________________________________________

5. Towhattypeofministrydoyoufeelcalled?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PERSONALREFERENCES(Non-family–thecollegewillrequestaletterfromeachlisted)Reference#1:___________________________________/____________________________ Last First Relationship:______________________________________________________StreetAddress:______________________________________________________________________City:_______________________________State:________________________Zip:________________Phone:Home(___)-____-______Cell(___)-____-______Email:____________________________


Reference#2:___________________________________/____________________________ Last First Relationship:______________________________________________________StreetAddress:______________________________________________________________________City:_______________________________State:________________________Zip:________________Phone:Home(___)-____-______Cell(___)-____-______Email:____________________________

EDUCATIONINFORMATION

HighSchool:_________________________________________________________________________StreetAddress:_______________________________________________________________________City:_______________________________State:________________________Zip:________________HighSchoolGraduate?qYesqNoDate:____________ HonorReceived:___________

College:____________________________________________________Major:_______________StreetAddress:______________________________________________________________________City:_______________________________State:________________________Zip:_______________CollegeGraduate?qYesqNoDate:____________ HonorReceived:________________

1. Areyoucurrentlyenrolledinschool? qYesqNo2. Wereyoueverexpelled,dropped,orsuspendedbyanyschoolorcollege?qYesqNo

Ifanswerisaffirmative,pleasegivecompletedetailsonaseparatesheetofpaper.

HealthInformation:Seeattached,StudentHealthHistoryandInsuranceAssessmentFormAreyoucoveredbyhealthinsurance?qYesqNoNote:PleaseprovideproofofinsuranceonHealthForm

Certification:I certify thatall informationsubmitted in theadmissionprocess; including theapplication, thepersonalessay,theconsentandauthorizationform,allsupplementaldocumentation,andanyothersupportingmaterialsismyownwork,factuallytrue,andhonestlypresented.

IherebyagreetoabidebytherulesandpoliciesofChristianLifeCollege.

SignatureofApplicant:__________________________________________Date__________________

Parent/Guardian’sSignature______________________________________Date__________________(Requiredifunderage18)

OFFICIALUSEONLY

ApplicationFeePAIDAMT$______________StudentNumber:_________________________________

DateEntered:_____________________ Enteredby:_____________________________________

GiftCertificate:$__________________ Representative/Event:____________________________

StudentReferredby:________________________________________________

ApplicationReviewedbyAdmissionsCommittee:qAccepted qDeniedDate:______________

AcceptanceLetterSent:________ Date:______________


FinalSectionInformationinreferenceto:“WhoorwhatinfluencedyoutoapplyforadmissiontoChristianLifeCollege?”

Ifparent: IsheorsheanalumnusofCLC/WABC? Yes_____ No____

Ifpastor: IsheorsheanalumnusofCLC/WABC? Yes_____ No____

Iffriend: IsheorsheaformerorcurrentstudentofCLC? Yes_____ No____

Ifconference: Whichconferencedidyouencounterourdisplay? _________________________________Year________

IfInternet: Whichplatformdidyouviewourpromotions? _____________________________________________

IfSOSTour: Whereandwhendidyouencounterourgroup(s)? _________________________________Year________

IfXperience: WheredidyouhearaboutXperience? _____________________________________________


Dear_____________________IamapplyingtoChristianLifeCollegeforstudentadmissionforschoolyear_____________/_______________(insertyears)AsIworktowardthecompletionofmyapplication,itisimportantformetoidentifytheindividualsbestequippedtowriteletterofrecommendationonmybehalf.Clearly,yournamecametomindasonewhowouldhavethebest/clearestperspectiveonmyexperiencesandabilities;andsoIamrequestingyoursupportinmyeffortstocontinuemyeducation.Youhavecontributedgreatlytomylife,andIwouldgreatlyappreciateyourhelpandfeelthatyourrecommendationwillhelpmesuccessfullycompletetheapplicationprocess;andultimatelyenrollment.Pleasecompleteandsendthisform,includingabriefrecommendationletterto:

ChristianLifeCollege|OfficeofAdmissions|9023WestLane|Stockton,California95210.

Aself-addressedenvelopeisincludedforyourconvenience.Thankyouverymuchforyourassistance. ApplicantName:_____________________________________________________

1.Howlonghaveyouknowntheapplicant?___________Howwelldoyouknowtheapplicant? qVerywell qModeratelywell qSlightly2.Whathasbeenyourrelationshiptotheapplicant?(checkasmanyasapply)qFamilyFriendqProfessionalcolleague qMentor qSchoolOfficial3.Pleaseratetheapplicantineachofthefollowingareas:.

Superior AboveAverage Average BelowAverage NotApplicable

Abilitytoworkwithothers Dependability EmotionalStability Leadership PersonalIntegrity SpiritualMaturity OverallEvaluation 4.Pleaseincludeadditionalcommentsaboutyourperceptionofthestudent’sfitforChristianLifeCollege:

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

DOESTHEAPPLICANTIMPRESSYOUASONEWHOSHOULDBEADMITTEDTOCHRISTIANLIFECOLLEGE?qNo qYes,butwithsomereservations qYes,withoutadoubt

IHAVEINCLUDEDMYPERSONALRECOMMENDATIONLETTER.qYes qNo

PRINTName:________________________________________________________________Signature:___________________________________________________Phone:___________________________EmailAddress:__________________________________________________________Date:_________________

GeneralREFERENCE &

RECOMMENDATION

[email protected]



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Singlepageform


Dear_____________________IamapplyingtoChristianLifeCollegeforstudentadmissionforschoolyear_____________/_______________(insertyears)AsIworktowardthecompletionofmyapplication,itisimportantformetoreceivearecommendationletterfromyou,myseniorpastor.Isincerelyappreciateyoutakingthetimetoassistmeinmypursuitofhighereducationandministry.Pleasecompleteandsendthisform,includingabriefrecommendationletterto:

ChristianLifeCollege|OfficeofAdmissions|9023WestLane|Stockton,California95210.

Aself-addressedenvelopeisincludedforyourconvenience.Thankyouverymuchforyourassistance. ApplicantName:_____________________________________________________

TotheSeniorPastor:1. Howlonghaveyouknowntheapplicant?____________________Inwhatrelationship?___________________

2. Istheapplicant’slifestyleuncompromisingandseparatedfromworldliness?____________________________

3. DoyouconsiderthispersontobeadedicatedChristian?_________Howlong?____________________

4. Toyourknowledgehastheapplicanteverbeenincarcerated?__________Why?________________________

5. Hasapplicanteverbackslidden,and/orinvolvedinimmorality?_____Ifyes,explain__________________________

6. Hasapplicanteverbeenmarried?________________Divorced?____________Separated?__________________

Forthefollowingitems,pleasecheckappropriateboxes.Ifappropriate,morethanonespacemaybecheckedpercategory

7. HOWDOESHIS/HERMANNER,APPEARANCEANDPERSONALITYAFFECTOTHERS?a. q Avoidedbyothers q Toleratedbyothers qWell-likedbyothers qSoughtoutbyothers

8. ISHE/SHEALEADERINYOURCHURCH? IFYES,WHATDEPARTMENT/POSITION?________________________

a. qMakesnoeffort qTriesbutlimitedabilityqHasleadershippromiseqMarkedabilitytolead

9. HOWISTHEAPPLICANTSSPIRITUALLIFE?a. qVeryPoorqNeedsImprovementqGoodqGreatandgrowingqStrong,veryspirituallymature

10. HOWISTHEAPPLICANTSINTEGRITY,MORALITYANDTRUSTWORTHINESS?

a. qPoor qAdequate qGoodqExemplary

11. HOWWOULDYOURATETHEAPPLICANT’SFAITHFULNESSTOCHURCH?a. qRarelyattends qOnlyspecialoccasions q50%ofthetime q100%ofthetime

12. HOWWOULDYOURATETHEAPPLICANT’SPERSEVERANCE(intaskcompletion)

a. qGivesupeasilyqNeedsmuchencouragementqUsuallypersistsq Persistsinspiteofadversity

13. DOESTHEAPPLICANTIMPRESSYOUASONEWHOSHOULDBEADMITTEDTOCHRISTIANLIFECOLLEGE?a. qNo qYes,butwithsomereservations qYes,withoutadoubt

NOTE:IHAVEINCLUDEDMYPERSONALRECOMMENDATIONLETTERONLETTERHEAD.qYes qNo IfNo,why?__________________________________________________________PRINTName:________________________________________________________________Signature:___________________________________________________Phone:___________________________EmailAddress:__________________________________________________________Date:__________________

Pastoral REFERENCE & RECOMMENDATION

[email protected]



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Singlepageform


LastName:________________________________________FirstName:______________________________MiddleInitial:_________

ID#:______________________________________________DateofBirth:_____/_____/______Age:_____Gender:�Male�Female

1.IMMUNIZATIONRECORD

PLEASESUPPLYDATESOFIMMUNIZATIONSANDPLEASEUPDATEIFNEEDED

Tetanus-Diphtheria(boosterwithinthelast10years._____________________________________________

MMR(Measles,Mumps,Rubella)Dose1________________________Dose2____________________________(twodatesrequired)

Measles(Rubeola):diseasedate________________Mumps:diseasedate__________________Rubella:diseasedate_______________

Polio:Completedprimaryseries?(4dates)Yes____Dateoflastbooster__________________IfNO,getcompletedseries.

HepatitisADose1_______________________Dose2_________________________(twodatesrequired)

HepatitisBDose1_______________________Dose2_________________________Dose3____________________(threedatesrequired)

MantouxTuberculosisTest(withinthepastyear)DateApplied_________________DateRead__________________Results_________

IfPOSITIVE,musthavechestx-raywithin2years.DateofCXR_______________Results____________________

MenactraA/C/Y/W-135(Meningococcalvaccine)_____________________________

2.VERIFICATIONBYCLINICIANOFPASTINFECTION(CLINICIAN-PLEASEINDICATEMONTHANDYEAR)

Measles Rubella HepatitisB

____________________________________________________________ClinicianSignature__________________________________

3.BLOODTESTInlieuofvaccinations,youmayprovideproofofimmunitybycheckingtheappropriatebox(es)andattachinglabresultstothisform.Serologicconfirmation(bloodtiter)ofimmunityattached:Measles�Rubella� HepatitisB�

4.MEDICALEXEMPTION(Physician/Clinicianpleasecheckappropriatebox)Icertifythatthemedicalcircumstancesoftheabove-namedstudentcontraindicateimmunizationagainst:

Measles&Rubella�HepatitisB�

_________________________________ ____________________Physician/Cliniciansignature DateClinicstamp,whereapplicable

5.OTHEREXEMPTION(Religiousorpersonalexemption-mustbereviewedwiththehealthcenterdirectorbyappointmentonly.)a)Irequestapersonal/religiousexemptionfromvaccinationsforthefollowingreason:

_________________________________________________________________________________________________________

StudentSignature:_______________________________Date:______________DirectorSignature:______________________

OR

HealthHistory&INSURANCE FORM

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3pageform


IcertifythatIwasbornpriortoJanuary1,1957,andattendedprimaryandsecondaryschoolintheUnitedStates,willnotresideinacampusresidencehall(dorm)andwillnotworkwithpre-schoolagechildrenorhealthcarepatientsaspartofmycollegeexperience.StudentSignature:_______________________________________________Date:__________________________Iunderstandthatexemptionforanyofthereasonslistedabovesubjectsmetoexclusionfromcampusintheeventofanoutbreakofadiseaseforwhichimmunizationisrequired.StudentSignature:_______________________________________________Date:__________________________

EmergencyContactintheUSA:

LastName__________________________________________________________FirstName__________________________________Relationship_____________________________________________________________________________________________________Address________________________________________________________________________________________________________Apt#___________________City_______________________________________________State______________Zip______________Phones(WK/HM/CELL)___________________________________________________________________________________________

Allergies:

Medications_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Others:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

MedicalAlerts:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________StudentSignature__________________________________________________________________________Date__________________

StudentAffairs

HealthInsuranceInformation-ForSchoolYear2017-2018

ChristianLifeCollegesuggeststhatALLCollegestudentsenrolledin7unitsormore,orlivinginon-campushousing,havehealthinsurance.STUDENTHEALTHINSURANCE

�Ihaveviablehealthinsurancewith:

InsuranceCompany:_________________________________________________PolicyNumber:_______________________Acopyofyourmedicalinsurancecard(frontandback)mustbeprovided.

Pleaseanswerthefollowingquestionsandsignbelow:Isthisafamilypolicy?No____Yes____Areyoucoveredafterage18?No___Yes___Areyoucoveredforaccident?No____Yes____Areyoucoveredforsickness?No___Yes___Doesyourpolicycovervisitstothedoctor’soffice?No____Yes____Willyourpolicypaytotalcosts?No___Yes___AretheregeographiclimitationsNo____Yes____withprescriptioncosts?No___Yes___StudentSignature______________________________________________________________________Date____________(SignatureofParent/Guardianifstudentisunder18yearsofage)


ENTRANCEIMMUNIZATIONREQUIREMENTS

ChristianLifeCollegeBoardofDirectorsrequiresthat:

1. ALLSTUDENTSbornonorafterJanuary1,1957,showproofoffullimmunizationagainstmeasles(rubeola)andrubella.Certaingroupsofstudentsregardlessofagemustalsoshowproofoffullimmunization.Thesegroupsinclude:studentswhoattendedK-12schooloutsidetheUS,studentswhohavelivedoutsidetheUSatanytimeduringthelast10years,andallstudentswhowillliveinthecampusresidencehall.

2. Allnewenrolleeswhoare18yearsofageoryoungershowproofofhavingcompleteda3doseseriesofimmunizationsagainstHepatitisB.

ImmunitytoMeasles(Rubeola)andRubellameans:Twodosesofmeaslesandrubellagivenindividuallyorincombination(MRorMMR)atorafter12monthsofageandatleastonemonthapart.ImmunitytoHepatitisBmeans:ThreedosesofHepatitisBvaccinegivenoveraperiodofapproximately6months.

Compliancewiththeserequirementscanbemetinthefollowingwaysandneedstobecompletedpriortoyournextregistrationperiod:

A.SubmitDocumentation

SendoneormoreofthefollowingdocumentstotheAdmissionsOfficewithyournameandStudentID#clearlyindicatedoneachdocumentsubmitted:

•AnImmunizationreport;completedbyyourphysicianorhealthcareprovider•Aphotocopyofyourchildhoodimmunizationrecord•AphotocopyofyourCaliforniaHighSchooltranscriptIFimmunizationinformationisdocumentedontranscript•Acopyofalabreportshowingproofofimmunitybybloodtiter

B.BeImmunized

Ifyoudon’thavedocumentation,beimmunizedat:•Yourfamilyphysician•AlocalclinicorCountyPublicHealthDepartment

C.Requestawaiverorexemption

•Medical:Ifyourmedicalcircumstancescontraindicateimmunization,haveyourphysiciancheckandsign#4onthefirstpageofthisdocument.

•Religious:Statelawpermitsexemptionfromimmunizationforthosewhoobjecttoimmunizationsonreligiousorpersonalgrounds.Thesewaiversarehandledonacase-by-casebasisandrequireanappointmentwiththeDirectorofAdmissionsforapproval.

D.StudentStatementofExemption

IfyouwerebornpriortoJanuary1,1957,andattendedK-12intheUS,havenotlivedoutsidetheUSatanytimeduringthelast10years,andwillnotresideinacampusresidencehall(dorm),pleasesign#5onfirstpageofthisdocument.

MailorFAXyourcompletedformsanddocumentationto:ChristianLifeCollege•AdmissionsOffice•c/oLairdSillimon9023WestLane•Stockton,CA95210•FAX:(209)952-5795

Oremailyourcompletedformsanddocumentationto:[email protected]

OFFICIALUSEONLY

PhysicianSignature_______________________________________________________Date____________

OfficePhone(_____)___________________ Address_______________________________________

Email_____________________________________ City,State,Zip_________________________________


Submitanessayofminimally500words,astatementofthecurrentstatusofcallandcommitmenttoChristianeducationandministry.Thestatementshouldinclude:

• conversionexperience,• familybackground,• spiritualdevelopment,• calltoministry,• spiritualandeducationalgoals.

AttachessaytothisformandsubmittoChristianLifeCollege.Essaymustbedigitallyexecutedtextfiles.(.doc,.docx,.pages,.pdf,etc.)Handwrittenisnotacceptable.StudentName____________________________________________________________________________________________LastFirstMiddle

o Ihavecompletedandattachedmyessaytothiscoverpage.

o Icertifythatmystatementisatrueandaccuraterepresentationofmybackgroundandgoals.

_______________________________________________________________________________________________________Student’sSignatureDate

StatementofPURPOSE

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Twopageform


A.NameofHighSchool___________________________________________________________________________________

Address________________________________________________________________________________________________

StreetCityStateZip

OR

B.NameofCollege______________________________________________________________________________________

Address_______________________________________________________________________________________________

StreetCityStateZip

To:InstitutionRegistrarThestudentlistedbelowisrequestingofficialtranscript(s)tobesenttoChristianLifeCollegeasanadmissionsrequirement.Thankyou.Pleasesendmyofficialtranscriptto:

ChristianLifeCollege

OfficeofAdmissions9023WestLaneStockton,CA95210StudentName____________________________________________________________________________________________LastFirstMiddleAddress_________________________________________________________________________________________________StreetCityStateZipName(s)registeredunder______________________________________________DateofBirth_______/_______/_______

SocialSecurity#______-______-______Iwasastudentfrom_______________________to_______________________

_______________________________________________________________________________________________________Student’sSignatureDate

TranscriptREQUEST FORM

[email protected]

2017-2018


(NonofficialStateofCaliforniaForm)

CreatedforuseofChristianLifeCollegeStudentInformationONLY

IDENTIFICATIONNUMBER YEARMODEL MAKE LICENSEPLATE

STUDENTNAME DRIVERLICENSE# STATEWHEREISSUED:

STUDENTSIGNATURE BIRTHDATE LICENSEEXPIRATION

ICERTIFYTHATTHEFOREGOINGISTRUEANDCORRECT.Ifurtherunderstand,agreeandwilladheretoallCLCandStateofCaliforniapoliciesregarding:parkinglotspeedlimits,parkingareasasdesignated,emergencyvehicleredcurb,andvehicleremovalofnon-workingornon-insuredvehicles.CLCreservestherighttofineand/ortownon-compliancevehicles.

Pleasecheckappropriatestatewherevehicleislicensed:

AB AL AR AZ BC CA CO CT DC DE

FL IL IN KS KY LA MA MB MD ME

MI MN MX NB NC ND NE NH NJ NL

NM NS NT OK ON OR PA PE QC RI

SC SD SK TN VT WA WI WV WY YT

StudentVehicleREGISTRATION

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2017-2018

2017 - 2018 complete application all pages -...

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