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Health Information and Interests
*
Please type your email here for ID purposes:
Health Information
In addition to answering the following questions, please print and send a
Personal Health Report
. This is required by New York State law.
Do you have physical or learning disabilities?
No
Yes
If yes describe:
Interests, Activities & Experience
Choose the number of years that you have been involved in each activity:
Yearbook staff:
0
1
2
3
4
5
6
7
8
9
10
more than 10
Drama team:
0
1
2
3
4
5
6
7
8
9
10
more than 10
Choir:
0
1
2
3
4
5
6
7
8
9
10
more than 10
Band / Orchestra:
0
1
2
3
4
5
6
7
8
9
10
more than 10
Student Council member:
0
1
2
3
4
5
6
7
8
9
10
more than 10
Church elder/deacon:
0
1
2
3
4
5
6
7
8
9
10
more than 10
Missionary service:
0
1
2
3
4
5
6
7
8
9
10
more than 10
Church volunteer:
0
1
2
3
4
5
6
7
8
9
10
more than 10
Youth group office:
0
1
2
3
4
5
6
7
8
9
10
more than 10
Sunday School teacher:
0
1
2
3
4
5
6
7
8
9
10
more than 10
Bible teacher:
0
1
2
3
4
5
6
7
8
9
10
more than 10
Home group leader:
0
1
2
3
4
5
6
7
8
9
10
more than 10
Community service projects:
0
1
2
3
4
5
6
7
8
9
10
more than 10
List community service projects:
List other interests or hobbies:
How did you first learn about Elim Bible Institute?
Parents
Elim Staff/faculty
Youthforce or Kingdom Force
Elim representative
Elim Alumnus
Pastor
Church
Web/Internet
Ad in Charisma Magazine
Ad in Campus Life Magazine
Current Elim student
Other (please describe)
Description of "Other" (above) or Student's Name:
References
List the name, complete address, and telephone number of your senior pastor, church leader (elder, deacon, Sunday School superintendent, youth director, etc.), and a non-church related teacher (an employer may be substituted if you have not attended school or college in over a year). None of your references should be related to you. If your parent is the senior pastor of your home church, an elder or church officer may act as the pastoral reference for you.
Senior Pastor
Name:
Address:
City:
State/Prov:
Zip/Postal Code:
Phone:
Church Leader
Name:
Address:
City:
State/Prov:
Zip/Postal Code:
Phone:
Teacher or Employer
Name:
Address:
City:
State/Prov:
Zip/Postal Code:
Phone:
Ask each of your references to complete a
Personal Reference Form
and have them return it to the Director of Admissions, Elim Bible Institute, 7245 College Street, Lima, NY 14485.
WAIVER OF ACCESS: The Family Rights and Privacy Act of 1974 provides the student the right to review all materials placed in his/her personal file after January 1, 1975, if admitted as a student. You may wish to waive the right to see the character references that are provided with the understanding that you will not see them. Check the box below which represents your wishes. This will in no way affect the decision of the Admissions Committee. The persons furnishing the references will be informed of your choice by the information you provide in the applicant's section of the Personal Reference Form. You must indicate the same choice below as you do on your Reference Forms. Please note: We expect you to indicate your choice regarding the Waiver of Access. If no choice is indicated, we will be unable to process your application.
I waive my right to see my character references under the provisions of the Family Rights and Privacy Act of 1974.
I do not waive my right to see my character references under the provisions of the Family Rights and Privacy Act of 1974.
If accepted, I agree to abide by the rules of Elim Bible Institute.*
*
Full name of applicant:
*
Date of Application (Mo./Day/Yr.):
*A paper copy of this statement will be sent to you once you submit your application.
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