City Care Institute

Application for Admission

INSTRUCTIONS

Complete this application. Please type or print all requested information. All portions of this application must be completed in order to be considered for admission.

Request official transcripts from high school and colleges be sent directly to City Care Institute.

Submit the completed application and the non-refundable $25 application fee directly to the City Care Institute.

I request admission for Year.

PERSONAL INFORMATION PERSONAL INFORMATION

Name

FIRST	MIDDLE	LAST	MAIDEN

Preferred First Name

Permanent Address

Mailing Address if different from above:

Email Address

Phone: Cell () Home ()	WK ()

Social Security Number Gender

Date of Birth Place of Birth

City State Nation

Marital Status Choose an item.

Spouses Name Number of Dependents Ages

Prior Military Service?	If yes, please specify:

List languages other than English that you speak fluently.

Ethnicity Choose an item.

Citizenship

Visa Type

School Date Graduated

Address

GED Date Place Received

List in order of attendance all post-secondary schools attended:

Name of College/University	City	State	Dates From To	Major Field of Study	Number of Hours Completed / GPA

Are you currently employed? Yes No How many hours do you work weekly?

Name of Company Current Position

Name of Supervisor and phone number

How long have you held your current position?

Starting with current employment list employment history

Company	City	State	Position	Dates From To

How did you hear about City Care Institute?

Type of Chaplaincy you may be interested in: Choose an item.

Other

What church do you currently attend:

Mailing Address

Street Number City State	Zip Code

Pastor’s Name:

Full and official title of Denomination/Fellowship

Are you a member? Yes No	Years of attendance:

Please list two (2) people, other than family members, who have known you for at least one year and who are willing to complete a separate, confidential personal recommendation for City Care Institute.

Name Relationship/Position

Mailing Address

Street Number City State Zip Code

Phone: Email:

Name Relationship/Position

Mailing Address

Street Number City State Zip Code

Phone: Email:

On a separate sheet of paper, briefly share your spiritual pilgrimage. Please include your salvation experience, your family’s church background and spiritual background, the major traumas that have occurred in your life or that of your family, any psychological counseling you have undergone, your key growth and development points with the Lord, and your current participation/involvement in your local church. Please be specific. Your essay should be approximately two to three pages (single spaced) in length. This important essay will constitute a sample of your English grammar /composition skills, and your ability to communicate clearly in written form.

I hereby apply for admission to City Care Institute and certify that to the best of my knowledge the information given in this form is correct. If admitted, I will uphold and abide by all the regulations and standards of City Care Institute, including the Standards of Conduct. I understand that confidential forms may be requested of persons named in this application. Such forms will be returned directly to City Care Institute with the understanding that their contents are not available to me. I hereby waive my right to their content. I understand that the information contained in my application and student file is available to the faculty and administration of City Care Institute for evaluation and advisement purposes.

Signature	Date

City Care Institute admits students without regard to race, color, sex, national or ethnic origin, handicap or disability, age, marital, or veteran status.

Completed application with attached essays $25.00 Application Fee Official transcripts requested

Please submit this completed application to:

City Care Institute

310 N Indian Hill, #154

Claremont, CA 91711

Phone: 909.454.7300

Click the Submit button to send directly to our email

Application Received by: Received Date:

Application Fee Received Cash Check Credit Card Date: