Dual Enrollment Form - www.kmbc.edu

Student Information

Name(Required)

First Middle Last

Gender(Required)

Male

Female

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Birth Date(Required)

Christian Experience

Home Church(Required)

Pastor's Name

Have you accepted Jesus as your personal Savior?(Required)

Yes

Unsure

Have you been sanctified wholly?(Required)

Yes

Unsure

In multiple senstences, explain the meaning that the Christian faith has for you. Describe your relationship to Jesus Christ. Include a statement indicating how you came to make such a commitment.(Required)

Educational Background

Name of High School(Required)

High School Address

Year of Highschool Graduation(Required)

Have you taken a standarized test (i.e. ACT, SAT, CLT)?(Required)

Yes

Currently Scheduled

Parent/Guardian Information

Name/s(Required)

Address (If different than above)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

I hereby make application to Kentucky Mountain Bible College under the dual-enrollment program and certify the truthfulness of the answers given herein. If admitted, I agree to subscribe willingly and faithfully to all policies and standards of the college. I also authorize my transcripts to be issued to my High School at the end of each semester.(Required)

Name

First Last

Date

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