holmes bible college application for...

21
HOLMES BIBLE COLLEGE APPLICATION FOR ADMISSION PLEASE PRINT IN INK OR TYPE. Please include with the application a $35.00 admissions fee. 1. I am applying for admission as follows: ____New Freshmen _____Transfer Year_______ Semester______ PERSONAL INFORMATION 2. Full Name_______________________________________________________________ Last First MI Preferred Name 3. Social Security Number __ __ __-__ __ - __ __ __ __ 4. Present Address___________________________________________________________ Street or PO Box _____________________________________________ ___________ ____________ City State Zip 5. Permanent Address_________________________________________________________ Street or PO Box ________________________________________________ ___________ ____________ City State Zip 6. E-Mail 7. Phone ______-______-_________ 8. Date of Birth ____/____/_________ Country of Birth___________________________ 9. Are you a U.S. Citizen? ___Yes ___No Country of citizenship_____________________ 10. Permanent Resident #________________ Student Visa #__________________________ 11. Do you consider English to be your native language? ___Yes ___No 12. If not, have you taken the TOEFL? ___Yes (Score_______) / ___No 13. Have you ever been convicted of a felony? ___Yes ___No (If yes, please explain on a separate sheet of paper.) 14. Military Veteran ___Yes ___No 15. Have you ever lived outside the U.S. for one year or more as a missionary kid or third-culture kid? ___Yes ___No

Upload: duongque

Post on 24-Apr-2018

216 views

Category:

Documents


3 download

TRANSCRIPT

Page 1: HOLMES BIBLE COLLEGE APPLICATION FOR …holmescollege.publishpath.com/Websites/holmescollege/files/Content/...October 30-Nov. 3 Missions Emphasis Week (SEND Conference Oct. 31-Nov

HOLMES BIBLE COLLEGE

APPLICATION FOR ADMISSION

PLEASE PRINT IN INK OR TYPE.

♦ Please include with the application a $35.00 admissions fee.

1. I am applying for admission as follows: ____New Freshmen _____Transfer

Year_______ Semester______

PERSONAL INFORMATION

2. Full Name_______________________________________________________________

Last First MI Preferred Name

3. Social Security Number __ __ __-__ __ - __ __ __ __

4. Present Address___________________________________________________________

Street or PO Box

_____________________________________________ ___________ ____________ City State Zip

5. Permanent Address_________________________________________________________

Street or PO Box

________________________________________________ ___________ ____________ City State Zip

6. E-Mail

7. Phone ______-______-_________

8. Date of Birth ____/____/_________ Country of Birth___________________________

9. Are you a U.S. Citizen? ___Yes ___No Country of citizenship_____________________

10. Permanent Resident #________________ Student Visa #__________________________

11. Do you consider English to be your native language? ___Yes ___No

12. If not, have you taken the TOEFL? ___Yes (Score_______) / ___No

13. Have you ever been convicted of a felony? ___Yes ___No

(If yes, please explain on a separate sheet of paper.)

14. Military Veteran ___Yes ___No

15. Have you ever lived outside the U.S. for one year or more as a missionary kid or third-culture

kid? ___Yes ___No

Page 2: HOLMES BIBLE COLLEGE APPLICATION FOR …holmescollege.publishpath.com/Websites/holmescollege/files/Content/...October 30-Nov. 3 Missions Emphasis Week (SEND Conference Oct. 31-Nov

The following questions are for statistical purposes only and are entirely voluntary. Holmes Bible College does

not discriminate on basis of race, color, sex, or national origin.

How would you describe yourself? (Please circle one.)

White Black Hispanic Native American Asian Pacific Islander

Marital Status (Please circle one.)

Single Married Widowed Separated Divorced

Family Information

16. Father's Name______________________________ Occupation_______________________

Address_____________________________________________________________________

Phone ______/______/________ Employer___________________________________

17. Mother's Name____________________________ Occupation_________________________

Address_____________________________________________________________________

Phone ______/______/________ Employer___________________________________

SPIRITUAL BACKGROUND

18. Church Name__________________________________ Denomination___________________

Pastor's Name__________________________________ Years as member ________________

Address______________________________________________________________________

19. Please List any ministries in which you have been involved.

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

Page 3: HOLMES BIBLE COLLEGE APPLICATION FOR …holmescollege.publishpath.com/Websites/holmescollege/files/Content/...October 30-Nov. 3 Missions Emphasis Week (SEND Conference Oct. 31-Nov

EDUCATIONAL EXPERIENCE

Applicants should arrange to have transcripts of all previous course work sent to Holmes Admissions Office.

20. What type of high school did you attend? (Please circle one.)

Public Private Home School GED

21. High School Data

Name_____________________________________Principal's Name____________________

School Address_______________________________________________________________

Phone/Fax/E-mail_____________________________________________________________

22. Please list any co-curricular activities in which you were involved.

___________________________________________________________________________

___________________________________________________________________________

____________________________________________________________________________

23. SAT / ACT Score_____________ Date Taken _____/_____/________

24. List any previous college work.

Name of College State Date Attended Units Earned

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

25. Prospective Major (Please circle one.) Christian Ministry Bible & Theology (Pre-Seminary)

26. Enrollment Status (Please circle one in each section.)

a. Day classes (on campus) BEAM Online

b. Full-time Part-time Audit Special Student

27. Are you applying to live in campus housing? ___Yes ___No

Note: All single students under 21 years of age not residing with parents or other relatives must apply

for campus housing.

Page 4: HOLMES BIBLE COLLEGE APPLICATION FOR …holmescollege.publishpath.com/Websites/holmescollege/files/Content/...October 30-Nov. 3 Missions Emphasis Week (SEND Conference Oct. 31-Nov

FINANCIAL INFORMATION

28. How do you plan to finance your education?

____________________________________________________________________________

___________________________________________________________

___________________________________________________________

I certify that the above information is true and accurate to the best of my knowledge, recognizing that the

purposely giving inaccurate information may result in dismissal from Holmes Bible College.

___________________________________ __ __/__ __/__ __ __ __

Signature Date

ESSAY QUESTIONS

Please answer the following questions on a separate sheet of paper in no more than one-hundred words

each.

1. Please describe your relationship with God, including your salvation experience and subsequent growth.

2. What are your spiritual, educational, and ministerial goals? How will attending Holmes Bible College

help you to achieve those goals?

3. Upon leaving Holmes Bible College, what do you expect to have gained from your experience? What do

you expect to have contributed to the institution?

PLEDGE

If accepted as a student at Holmes, I agree to conduct myself with honor and charity, to build a strong

Christian community, and to be governed by the principles stated in the Academic Catalog and the Student

Handbook. I recognize that attendance at Holmes is a privilege and not a right and that this privilege may be

forfeited.

Applicant's Signature_______________________________________ Date________________

The parent or guardian of the student making application must sign in the space provided below if the applicant

is under eighteen years of age.

Signature of Parent or Guardian______________________________ Date_________________

If signature is that of a legal guardian, the following information is necessary:

Name_____________________________________________________________________________

Complete Address___________________________________________________________________

Page 5: HOLMES BIBLE COLLEGE APPLICATION FOR …holmescollege.publishpath.com/Websites/holmescollege/files/Content/...October 30-Nov. 3 Missions Emphasis Week (SEND Conference Oct. 31-Nov

Mail Application to: Holmes Bible College, P.O. Box 14188, Greenville, SC 29610-4188.

Page 6: HOLMES BIBLE COLLEGE APPLICATION FOR …holmescollege.publishpath.com/Websites/holmescollege/files/Content/...October 30-Nov. 3 Missions Emphasis Week (SEND Conference Oct. 31-Nov

Admissions Checklist

___ Completed Application Form ___ Application Fee ___ Completed Essay Questions ___ Pastoral reference ___ Personal Reference (2) ___ High School/GED and College Transcripts (if applicable) ___ ACT/SAT Scores ___ Photo (optional) ___ Physical Exam Form ( (optional for U.S. Citizens; required for international applicants)) ___ INS Form I–134 or Affidavit of Support (international students) ___ TOEFL Scores (if English is your second language) Congratulations! You have completed the application procedures for Holmes Bible College. Should you have any questions or concerns about your application or college life and practice in general, please call us at 864-246-3566.

Page 7: HOLMES BIBLE COLLEGE APPLICATION FOR …holmescollege.publishpath.com/Websites/holmescollege/files/Content/...October 30-Nov. 3 Missions Emphasis Week (SEND Conference Oct. 31-Nov
Page 8: HOLMES BIBLE COLLEGE APPLICATION FOR …holmescollege.publishpath.com/Websites/holmescollege/files/Content/...October 30-Nov. 3 Missions Emphasis Week (SEND Conference Oct. 31-Nov

Holmes Bible College

2017-2018

Calendar

Fall 2017

August 17 Faculty/Staff Workshop

August 18 Freshman Students Arrive

August 18-20 Freshman Registration/Orientation

August 21-22 Returning Students Registration

August 23 Classes Begin

August 27-30 Opening Revival

August 30 Final Day to Enter Fall Semester

September 4 Labor Day (No classes)

October 5 Feast of Ingathering

October 8 Final Day to Drop Class(es)

October 19-20 Fall Break

October 30-Nov. 3 Missions Emphasis Week (SEND Conference Oct. 31-Nov. 1)

November 13-17 Spring 2018 Pre-Registration

November 22-27 Thanksgiving Break

December 11-13 Fall Semester Exams

December 13 Semester Ends

Spring 2018

January 5 Faculty/Staff Workshop

January 8 Spring 2018 New Students Arrive/Registration

January 8-9 Spring 2018 Registration

January 10 Classes Begin

January 15 Martin Luther King, Jr. Day (No classes)

January 17 Final Day to enter Spring Semester

March 7 Final Day to Drop Class (es)

March 7-10 Founders Week/Homecoming

March 12-16 Spring 2018 Break

April 2 Easter Monday (No classes)

April 3-6 Fall 2018 Pre-Registration

April 30-May 2 Spring 2018 Semester Exams

May 3 School-wide Outing – 2:00 p.m.

May 4 Honors Night/Hooding Ceremony – 7:00 p.m.

May 5 Graduation – 10:30 a.m.

Page 9: HOLMES BIBLE COLLEGE APPLICATION FOR …holmescollege.publishpath.com/Websites/holmescollege/files/Content/...October 30-Nov. 3 Missions Emphasis Week (SEND Conference Oct. 31-Nov
Page 10: HOLMES BIBLE COLLEGE APPLICATION FOR …holmescollege.publishpath.com/Websites/holmescollege/files/Content/...October 30-Nov. 3 Missions Emphasis Week (SEND Conference Oct. 31-Nov

Holmes Bible College

Fall Semester 2017

HOUR COURSE DAYS PLACE INSTRUCTOR

8:00-8:50 GEO 101 World Geography M-W-F Room 201 Mr. Shealy GRE 401 Intermediate Greek I M-W-F Room 103 Mr. McKinney 8:00-9:15 ENG 101 English Composition I T-Th Room 201 Mr. Woodward GRE 301 Elementary Greek I T-Th Room 103 Mr. McKinney MIN 401 Past. Theo. & Church Admin. T-Th Room 105 Rev. Barr 9:00-9:50 MUS 201 Practical Music Skills M-W-F Room 105 Mrs. Watson

MIN 201 Life and Work of the Minister M-W-F Room 207 Rev. Barr THE 301 Christian Ethics M-W-F Room 103 Mr. McKinney OLD 401 Poetic and Wisdom Literature M-W-F Room 201 Mr. Shealy 9:25-10:40 ENG 099 Developmental English T-Th Room 105 Mr. Woodward CEY 201 Courtship, Marriage and Family T-Th Room 207 Rev. Kilgore MIN 301 Homiletics I T-Th Room 103 Rev. Barr

NEW 401 Romans and Galatians T-Th Room 201 Pres. Thompson

10:00-10:50 HIS 101 Western Civilization I M-W-F Room 201 Mr. Shealy NEW 313 Prison & Pastoral Epistles M-W-F Room 207 Rev. Watford THE 401 Apologetics M-W-F Room 103 Dr. Freeman 11:00-11:50 Chapel M-W Chapel SFD 208 Spiritual Formation T Chapel Pres. Thompson PRM 432 Senior Seminar F Room 103 Pres. Thompson MUS 206 Music Ministry Th Room 105 Mrs. Watson MUS 206 Ensemble F Chapel 12:00 Lunch 12:45-2:00 OLD 101 Old Testament Survey M-W Room 207 Rev. Watford BIB 203 Hermeneutics M-W Room 103 Mr. McKinney

OLD 313 Major Prophets M-W Room 201 Mr. Shealy 1:10-2:25 THE 201 Christian Theology I T-Th Room 201 Mr. McKinney CEY 301 Christian Education Ministries T-Th Room 103 Rev. Kilgore

2:00-3:15 MIS 401 Cross-Cultural Comm. M-W Room 201 Rev. Barr 6:00-8:30 SPA 201 Elementary Spanish I T Room 103 Mrs. Clement 7:00-9:30 CSC 101 Computer Literacy (Section One) M Computer Lab Rev. Malone CSC 101 Comp. Lit. (Section Two) TH

MUS 203-206 Applied Piano TBA Mrs. Watson MUS 213-14 Applied Voice TBA Mrs. Watson

Page 11: HOLMES BIBLE COLLEGE APPLICATION FOR …holmescollege.publishpath.com/Websites/holmescollege/files/Content/...October 30-Nov. 3 Missions Emphasis Week (SEND Conference Oct. 31-Nov

BEAM (Biblical Education for Adults in Ministry) Session One August 21- October 2 6:00-10:00 HIS 101 Western Civ. I M Room 207 Mr. Shealy August 24 - September 21 6:00 – 10:00 BIB 101 Old Testament Survey Th Room 207 Session Two October 9 – Nov. 6 6:00–10:00 BIB 102 New Testament Survey M Room 207 Sept. 28-November 2 6:00–10:00 MIN 201 Life and Work of the Minister Th Room 207 Dr. Allen Session Three November 13 – December 11 6:00-10:00 GOV 102 American Government M Room 207 Mr. Shealy November 9 – December 14 6:00-10:00 MIN 301 Homiletics I Th Room 207 Online Session One – August 23-October 11 Session Two: Oct. 18-Dec. 6 BIB 101 Old Testament Survey - Dupont NEW 102 New Testament Survey - Dupont ENG 101 English Composition I - Wheeler ENG 102 Eng. Comp. II - Wheeler OLD 202 Pentateuch - Watford NEW 202 Life of Christ - Dupont THE 301 Christian Ethics - Watford NEW 302 Acts of the Apostles - Dupont THE 401 Apologetics - Petty OLD 302 Hist. Books - Watford NEW 401 Romans and Galatians - Leggett NEW 402 I and II Cor. - Leggett OLD 401 Poetic and Wisdom Literature - Watford BIB 203 Hermeneutics - Watford THE 201 Christian Theology I - Watford THE 202 Theology II - Watford NEW 303 General Epistles - Dupont THE 302 Pent. Hist. and Theo. - Dupont

HIS 302 Church History – Petty

Page 12: HOLMES BIBLE COLLEGE APPLICATION FOR …holmescollege.publishpath.com/Websites/holmescollege/files/Content/...October 30-Nov. 3 Missions Emphasis Week (SEND Conference Oct. 31-Nov

Pastoral Reference Form

A. This portion is to be completed by the applicant.

Complete section A and give this form to your pastor or to a pastoral figure in your life. Ask him/her to

complete the form, sign it, and return it to:

Holmes Bible College, Office of Admissions, PO Box 14188, Greenville, SC 29610-4188.

Applicant's Name ___________________ Social Security#__ __ __ - __ __ - __ __ __ __

Address____________________________________________________________________________

The Family Educational Rights and Privacy Act of 1974 permits a matriculated student to have access

to his/her file unless a waiver of that right has been signed. If you wish to waive your rights to access

your file, sign your name in the space provided. The waiver is NOT required for admissions.

I hereby waive my right of access to this letter of recommendation.

____________________________________________ _______________

Applicant's Signature Date

B. This portion is to be completed by a pastor or pastoral figure.

The above named applicant is applying for admission to Holmes Bible College. The Admissions Office

finds candid, thorough, honest evaluations essential to the decision-making process. Please complete

the form to the best of your knowledge and include with it any information you believe to be pertinent

to an admissions decision. Your prompt appraisal of the applicant is highly appreciated. Thank you.

Please rate the applicant in each of the following areas with one (1) considered weak and ten (10)

considered strong:

Creativity 1 2 3 4 5 6 7 8 9 10

Academic Ability 1 2 3 4 5 6 7 8 9 10

Ingenuity 1 2 3 4 5 6 7 8 9 10

Oral Expression 1 2 3 4 5 6 7 8 9 10

Written Expression 1 2 3 4 5 6 7 8 9 10

Page 13: HOLMES BIBLE COLLEGE APPLICATION FOR …holmescollege.publishpath.com/Websites/holmescollege/files/Content/...October 30-Nov. 3 Missions Emphasis Week (SEND Conference Oct. 31-Nov

Do you believe that this applicant is truly called and gifted for ministry? ___Yes ___No

Do you believe that this applicant is spiritually ready for collegiate study? ___Yes ___No

Do you believe that this applicant has leadership potential? ___Yes ___No

Do you believe that this applicant has the maturity to pursue collegiate study? ___Yes ___No

How long and well have you known the applicant?

What specific talents and strengths have you witnessed in this applicant?

What specific weaknesses have you witnessed?

Do you wish to make any other comment about this applicant's preparation or maturity?

I ___Recommend ___Do Not Recommend ___Recommend with Reservation.

Name______________________________________________________________________________

Address____________________________________________________________________________

Phone ______-______-____________

Email (one character per box)

Page 14: HOLMES BIBLE COLLEGE APPLICATION FOR …holmescollege.publishpath.com/Websites/holmescollege/files/Content/...October 30-Nov. 3 Missions Emphasis Week (SEND Conference Oct. 31-Nov

Personal Reference Form

A. This portion is to be completed by the applicant.

Complete section A and give this form to someone who knows you well. (NOT a relative). Ask him/her

to complete the form, sign it, and return it to:

Holmes Bible College, Office of Admissions, PO Box 14188, Greenville, SC 29610-4188.

Applicant's Name__________________________ Social Security # __ __ __- __ __ -__ __ __ __

Address____________________________________________________________________________

The Family Educational Rights and Privacy act of 1974 permits a matriculated student to have access

to his/her file unless a waiver of that right has been signed. If you wish to waive your rights to access

your file, sign your name in the space provided. The waiver is NOT required for admissions.

I hereby waive my right of access to this letter of recommendation.

____________________________________________ _______________

Applicant's Signature Date

B. This portion is to be completed by someone (not a relative) who knows the applicant well.

The above named applicant is applying for admission to Holmes bible College. The Admissions Office

finds candid, thorough, honest evaluations essential to the decision-making process. Please complete

the form to the best of your knowledge and include with it any information you believe to be pertinent

to an admissions decision. Your prompt appraisal of the applicant is highly appreciated. Thank you.

Please rate the applicant in each of the following areas with one (1) considered weak and ten (10)

considered strong:

Creativity 1 2 3 4 5 6 7 8 9 10

Academic Ability 1 2 3 4 5 6 7 8 9 10

Ingenuity 1 2 3 4 5 6 7 8 9 10

Oral Expression 1 2 3 4 5 6 7 8 9 10

Written Expression 1 2 3 4 5 6 7 8 9 10

Page 15: HOLMES BIBLE COLLEGE APPLICATION FOR …holmescollege.publishpath.com/Websites/holmescollege/files/Content/...October 30-Nov. 3 Missions Emphasis Week (SEND Conference Oct. 31-Nov

Do you believe that this applicant is truly called and gifted for ministry? ___Yes ___No

Do you believe that this applicant is spiritually ready for collegiate study? ___Yes ___No

Do you believe that this applicant has leadership potential? ___Yes ___No

Do you believe that this applicant has the maturity to pursue collegiate study? ___Yes ___No

How long and well have you known the applicant?

What specific talents and strengths have you witnessed in this applicant?

What specific weaknesses have you witnessed?

Do you wish to make any other comment about this applicant's preparation or maturity?

I ___Recommend ___Do Not Recommend ___Recommend with Reservation.

Name______________________________________________________________________________

Address____________________________________________________________________________

Phone ______-______-____________

Email (one character per box)

Page 16: HOLMES BIBLE COLLEGE APPLICATION FOR …holmescollege.publishpath.com/Websites/holmescollege/files/Content/...October 30-Nov. 3 Missions Emphasis Week (SEND Conference Oct. 31-Nov

Personal Reference Form

A. This portion is to be completed by the applicant.

Complete section A and give this form to someone who knows you well. (NOT a relative). Ask him/her

to complete the form, sign it, and return it to:

Holmes Bible College, Office of Admissions, PO Box 14188, Greenville, SC 29610-4188.

Applicant's Name__________________________ Social Security # __ __ __- __ __ -__ __ __ __

Address____________________________________________________________________________

The Family Educational Rights and Privacy act of 1974 permits a matriculated student to have access

to his/her file unless a waiver of that right has been signed. If you wish to waive your rights to access

your file, sign your name in the space provided. The waiver is NOT required for admissions.

I hereby waive my right of access to this letter of recommendation.

____________________________________________ _______________

Applicant's Signature Date

B. This portion is to be completed by someone (not a relative) who knows the applicant well.

The above named applicant is applying for admission to Holmes bible College. The Admissions Office

finds candid, thorough, honest evaluations essential to the decision-making process. Please complete

the form to the best of your knowledge and include with it any information you believe to be pertinent

to an admissions decision. Your prompt appraisal of the applicant is highly appreciated. Thank you.

Please rate the applicant in each of the following areas with one (1) considered weak and ten (10)

considered strong:

Creativity 1 2 3 4 5 6 7 8 9 10

Academic Ability 1 2 3 4 5 6 7 8 9 10

Ingenuity 1 2 3 4 5 6 7 8 9 10

Oral Expression 1 2 3 4 5 6 7 8 9 10

Written Expression 1 2 3 4 5 6 7 8 9 10

Page 17: HOLMES BIBLE COLLEGE APPLICATION FOR …holmescollege.publishpath.com/Websites/holmescollege/files/Content/...October 30-Nov. 3 Missions Emphasis Week (SEND Conference Oct. 31-Nov

Do you believe that this applicant is truly called and gifted for ministry? ___Yes ___No

Do you believe that this applicant is spiritually ready for collegiate study? ___Yes ___No

Do you believe that this applicant has leadership potential? ___Yes ___No

Do you believe that this applicant has the maturity to pursue collegiate study? ___Yes ___No

How long and well have you known the applicant?

What specific talents and strengths have you witnessed in this applicant?

What specific weaknesses have you witnessed?

Do you wish to make any other comment about this applicant's preparation or maturity?

I ___Recommend ___Do Not Recommend ___Recommend with Reservation.

Name______________________________________________________________________________

Address____________________________________________________________________________

Phone ______-______-____________

Email (one character per box)

Page 18: HOLMES BIBLE COLLEGE APPLICATION FOR …holmescollege.publishpath.com/Websites/holmescollege/files/Content/...October 30-Nov. 3 Missions Emphasis Week (SEND Conference Oct. 31-Nov

Holmes Bible College

Tuition and Fees

2017-18

Application Fee $35

Tuition $90 per credit hour

Audit $45 per credit hour

Room and Board $1,200 per semester

General Fee (non-refundable):

10 or more credit hours: $125 per semester

6-9 credit hours $90 per semester

or fewer hours $60 per semester

Private Voice and Piano: $25 sign-up fee plus $90 per credit hour

Graduation Fee:

B.A., B.S., or A.A. Degree $50

Transcript Fee $ 5

Page 19: HOLMES BIBLE COLLEGE APPLICATION FOR …holmescollege.publishpath.com/Websites/holmescollege/files/Content/...October 30-Nov. 3 Missions Emphasis Week (SEND Conference Oct. 31-Nov
Page 20: HOLMES BIBLE COLLEGE APPLICATION FOR …holmescollege.publishpath.com/Websites/holmescollege/files/Content/...October 30-Nov. 3 Missions Emphasis Week (SEND Conference Oct. 31-Nov

Holmes Bible College

Physical Examination Form

Holmes encourages, but does not absolutely require, its applicants to have the following tests and

immunizations. This information will not be used to make an admissions decision, but is for the health

and safety of the student. This form is to be completed by a physician and mailed from that physician's

office directly to:

Admissions Committee, Holmes Bible College, PO Box 14188, Greenville, SC 29610-4188.

Name Date of Birth Sex

Height Weight Pulse Blood Pressure

Allergies

Tuberculin: Date Given Date read Results

Urinalysis: Albuman Sugar Microscopic

Heart: Normal Abnormal

Immunization required (Inoculations):

Date original series completed Date of last booster

Polio (Salk)

Polio (Sabin Oral)

Tetanus Toxoid

Are there any psychological problems of which the school should be aware?

Any episodes of unconsciousness or seizures?

Page 21: HOLMES BIBLE COLLEGE APPLICATION FOR …holmescollege.publishpath.com/Websites/holmescollege/files/Content/...October 30-Nov. 3 Missions Emphasis Week (SEND Conference Oct. 31-Nov

Please check below the activity you recommend. State reasons for restrictions, if any.

All forms of athletics and physical activity

All but most strenuous athletics and physical activity

Restricted, supervised physical education and physical activity

No forms of athletics or physical activity

Recommendations: (Regarding health, physical activity, or treatment)

Date Signature of physician

Printed name of physician

Physician's address

Parental permit (if applicable): The law requires parental permission before operative procedure on minors. No

operation will be performed except in an extreme emergency without parents being contacted and informed. To

care for such emergency, it is desirable that the parent sign the following consent form.

I hereby give authority to the college administration to sign for any emergency operation on

.

Date Parent's signature