Application Form - GCBI North

Name *

First

Last

Date of Birth (MM/DD/YYYY) *

Sex *

Male
Female

Email *

Phone *

Street Address *

City *

Province/State *

Postal Code/Zip *

Country *

Citizenship *

Marital Status *

Do you have any children? *

Yes
No

Parent/Guardian Name *

First

Last

Parent/Guardian Email

Parent/Guardian Address: Street, City, Province/State, Postal Code/Zip, Country

Which Address should we send the billing statement to? *

Student Address
Parent/Guardian
Other (please specify below)

Alternate billing address

Do you have any physical condition or medical condition that has or still requires professional care that might limit your activity in any way? *

Yes
No

Have you ever been treated by a psychologist or psychiatrist? *

Yes
No

Indicate the duration of the treatment and the nature of your condition or problem. If you are currently being treated, please have your doctor write a letter specifying the details of your treatment including medication and dosages.

Have you every been subject to any employee/ student disciplinary action? *

Yes
No

Have you ever been evicted from a residence? *

Yes
No

Have you every been subject to a formal complaint submitted to a police department? *

Yes
No

Have you ever been convicted of a crime? *

Yes
No

List in chronological order, starting with the most recent, schools and colleges you have attended with dates of attendance, date of graduation (or expected graduation date), and major field(s) of study. *

Have you previously applied for any program at GCBI (including Florida campus)? *

Yes
No

Name of the church you regularly attend *

How long have you been attending there? *

Please list any areas of ministry that you would be interested in trying out and growing in *