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Christian World Center Please attach
International School Programs Application for Resident Admission current picture
Deadline for application: First Semester - August 1; Second Semester - December 10

Student Information

Student's full name __________________________________________________________________ Preferred name ______________________ Student's home address ___________________________________________________________________________________________________ ____________________________________________________________________________________________________ Phone _________________________________ Fax ___________________ E-mail________________________________ Current grade _____ Applying for grade ______ 1st or 2nd Semester, 20______ Age _____ Birth date _____/_____/__________ Gender _____ City of Birth ________________________________ Passport Number________________________________________________ Citizenship ____________________________________________ ID Number _______________________________________________ Applicant lives with: _____ Other: _____________________________________________________________ (check any that apply)
_____ Parents are separated _____ Father has custody _____ Applicant is adopted _____ Mother is deceased _____ Parents are divorced _____ Mother has custody
Parent/Guardian Information
Father's full name (Mr./Rev./Dr.) _____________________________________________________________________________________________ Mother's full name (Mrs./Ms./Dr.) ____________________________________________________________________________________________ Parents' home address ______________________________________________________ City _________________________________________ Country _______________ Zip ___________________ Phone __________________ Fax________________ E-mail____________________ Father's profession ______________________________________________ Business phone __________________________________________ Mother's profession _____________________________________________ Business phone __________________________________________ Current church name and denomination ___________________________________________ Pastor’s name _____________________________ (Regular attendance at a local church is required.)
Has applicant (or other family members) previously attended Ben Lippen School? □Yes □No
If yes, please indicate name, dates & location: ________________________________________________________________________________


Brothers/Sisters (name, grade, school currently attending)___________________________________________________________________________
Academic Information
Name of previous school _______________________________________________________________ Phone ___________________________
School address _______________________________________________________________________ Fax _____________________________
Current or last semester letter grade in each subject: English/Spelling _____ Mathematics _____ Social Studies/History _____
Natural Science_____
Has applicant ever been referred for academic evaluation, either remedial or accelerated? □Yes □No If yes, please explain on a separate page.

Does applicant currently have a learning disability? □Yes □No Will applicant be enrolled in the learning disabilities (Discovery) program?

□Yes □No
Has applicant ever been suspended or dismissed for academic, disciplinary, or other reasons? □Yes □No If yes, please explain on a separate page.
English as a Second Language (ESL) Has applicant had any ESL courses? □Yes □No How long has applicant studied English?
TOEFL score ________ Will applicant enroll in ESL? □Yes □No Which level? □Beginning □Intermediate □Advanced

Medical Information
Does applicant have a physical health problem of which the school should be aware? □Yes □No If yes, please specify (include prescriptions or
limitations of normal activities): ____________________________________________________________________________________________
Is applicant taking any medication on a regular basis, such as Insulin, Ritalin, Prozac, etc.? □Yes □No Please list:
______________________________ Has applicant ever consulted, or been referred to, a psychiatrist, psychologist, or psychiatric social worker for professional assistance? □Yes □No If yes, please describe the circumstances: ___________________________________________________________________________________
Does applicant have a mental health problem of which the school should be aware? □ Yes □ No If yes, please specify (include prescriptions or
limitations of normal activities):_____________________________________________________________________________________________
Check any of the following used or experimented with (in the last 12 months): □narcotic drugs □tobacco □alcoholic beverages □stimulants

If checked, please explain: _________________________________________________________________________________________________

Please list the names and addresses in full of three adults to whom you have given a reference form.

Pastor ___________________________________________________________________________________________________________________
English Teacher ____________________________________________________________________________________________________________ Math Teacher ______________________________________________________________________________________________________________ From what source did you learn about CIP ? _____________________________________________________________________________________ Will you be applying for financial assistance? □Yes □No Have you already completed the necessary forms? □Yes □No
This application for admission is not complete until the following items are received:
1. A non-refundable application fee of fifty dollars ($100.00)
2. Previous school records including current grades and standardized test scores
3. Parent and student questionnaires 4. All reference forms 5. A 6. Admissions test results (when applicable) To the best of our knowledge the above information is correct.



Please return the completed application to:

__________________________________________________________________ Phone: 82-11-453-1033 Fax: 82-33-642-5098 Referral Information:



Christian World Center International School Programs is a ministry of Christian World Center and is a Christian, co-educational, college-preparatory
school. It is a member of the Association of Christian Schools International (ACSI) Notice of Nondiscriminatory Policy
Christian World Center International School Programs admits students of any race, color, sex, national and ethnic origin to all the rights, privileges, programs and activities generally accorded or made available to students at the school. It does not discriminate on the basis of race, color, sex, national and ethnic origin in administration of its educational policies, admissions policies, scholarship program, athletic or other school-administered programs. 본 원서는 전세계 크리스천학교들의 공용으로 사용 되어짐으로 영문으로 정확하게 각 질문 사항을 기입해 주세요.


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