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About
The KI Student
Our Campus
Board Members
Teaching Faculty
Meet Our Staff
Core Values
What We Believe
FAQs
Future Students
Academics
Discipleship
Community
Tuition
Weekly Schedule
Israel Trip
Campus Tours / Schedule a Visit
Apply Now
KI Alumni
Contact
Give Now
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About
The KI Student
Our Campus
Board Members
Teaching Faculty
Meet Our Staff
Core Values
What We Believe
FAQs
Future Students
Academics
Discipleship
Community
Tuition
Weekly Schedule
Israel Trip
Campus Tours / Schedule a Visit
Apply Now
KI Alumni
Contact
Give Now
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About
The KI Student
Our Campus
Board Members
Teaching Faculty
Meet Our Staff
Core Values
What We Believe
FAQs
Future Students
Academics
Discipleship
Community
Tuition
Weekly Schedule
Israel Trip
Campus Tours / Schedule a Visit
Apply Now
KI Alumni
Contact
Give Now
Apply Now
About
The KI Student
Our Campus
Board Members
Teaching Faculty
Meet Our Staff
Core Values
What We Believe
FAQs
Future Students
Academics
Discipleship
Community
Tuition
Weekly Schedule
Israel Trip
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Student Commitment to Excellence Contract and Tuition Agreement
Name
First
Last
Financial Commitment
I promise to pay my tuition in full and communicate with the Kanakuk Institute about my financial situation.
Yes
No
I understand that a $250 non-refundable deposit is required to reserve my spot at the Kanakuk Institute. This will go toward my tuition.
Yes
No
I understand if I would like the $7,500 scholarship I am committing to 5 hours of campus work per week (2 hours in dining hall and 3 hours on campus).
Yes
No
I will fulfill this scholarship opportunity to the best of my ability and recognize if I fail to fulfill my duties my scholarship will be reduced based on the number of hours not completed.
Yes
No
If for any reason I choose not to complete the program after the start date in September, I understand I am still responsible to pay the full tuition amount.
Yes
No
I understand that if my tuition is not paid completely by graduation date that I will pursue a loan and that the Institute reserves the right to charge interest on any outstanding debt (currently 5% annually and subject to change without notice).
Yes
No
Select the appropriate box below. Every student will benefit from the the $7,500 work study scholarship.
Please check one.
Single Student - Work Study Scholarship
Married Students
I understand the commitments I am making and promise to follow through on them.
Full Name
*
First
Middle
Last
Signature
*
Health, History, and Emergency Contact Info
Email Address
Date of Birth
Date Format: MM slash DD slash YYYY
Emergency Contact Info
Name
Relationship
Daytime Phone
Cell Phone
Please list at least two emergency contacts.
Use the '+' button to add additional rows.
HEALTH DISCLOSURE STATEMENT: For the protection of your safety and the well being of all the students at the Kanakuk Institute, FULL disclosure must be made regarding any PHYSICAL, SOCIAL, AND/OR PSYCHOLOGICAL CONDITIONS. Failure to do so may result in your discharge from the program and the forfeiture of your tuition. Disclosure of health history is crucial to our ability to provide a supportive, safe and healthy learning environment for you. Please make a copy of this form and keep for your records.
Allergies
Check those that apply to you:
I am allergic to peanuts and/or nuts.
I am allergic to these substances (mold, dust, insect stings, other)
I have allergies to some types of drugs.
Please provide details about any allergies.
Chronic Concerns
Check all categories that pertain to you and provide information about supportive health care.
Anorexia/Bulimia (Eating Disorders)
Anxiety
Asberger's / Downs / Autistic
Asthma (even if only occasionally uses inhaler)
Bi-Polar/Psycho/Social Disorder
Bleeding Disorders
Celiac Disease
Depression
Diabetes
Eczema
Hearing/Visually Impaired
Knee Problems (total knee replacement, ACL, etc.)
Muscular Coordination
Oppositional Behavior Disorder
Special Diet
Seizure Disorder
Suicidal Tendencies
Tourettes Syndrome
What Year Diagnosed with Diabetes?
Insulin Pump
*
Yes
No
Please provide details about any items checked above.
Prescription Medication
Name of Medication
Reason for Taking
Dose Taken
Time Taken Each Day
Please provide complete information on any medication taken on a regular basis.
Use '+' to the right to add additional rows.
I do not take any medications on a regular basis.
Medical Insurance Carrier
Medical Insurance Policy #
Student Health Questionnaire
Please note this information will be made available ONLY to those who will be working directly with your care. This information is to help us assist you in having the very best experience possible!
List and discuss any special needs you may have as well as other physical or psychological conditions (other than those noted on the Health Form):
Are there any special concerns you have regarding your year at the Institute?
Are there any pre-existing conditions that you have that may hinder your ability to take part in athletic activities at the Institute?
Is there any medical condition that you have that you would want to ensure that we were aware of?
Have you been hospitalized or had surgery for anything in the past 2 years; please be specific
Have you ever had or been treated by a Doctor for any of the following conditions:
Ears/Nose/Throat
Eyes
Heart
Lungs
Abdomen
Skin
Neck
Back
Shoulder/Arms
Elbow/Forearms
Wrist/Hand
Hip/Thigh
Knee
Leg/Ankle
Foot
Heart Disease
Stroke
High Blood Pressure
Cancer
Diabetes
Faintness during exercise
Dizziness during and after exercise
Shortness of breath
Muscle Weakness
Joint/Pain Stiffness
Heart Murmur
Irregular Heart Beat
Seizures
Orthopedic Injury
Weight Loss/Anorexia
Frequent Ear Infections
Hearing Visual Disorder
Migraine Headaches
Orthopedic Disorder
Eneuresis
You checked Orthopedic Disorders, could you please explain further?
Do you have any restrictions on your activities?
Yes
No
Activities restricted by whom?
What kind of activities are you restricted from?
Have you been hospitalized in the last year?
Yes
No
Please explain the reason for your hospitalization(s)
AUTHORIZATION FOR HEALTH CARE
To the best of my knowledge, all information provided on this form is accurate and complete. I am in good health and able to participate in all Kanakuk Institute activities. I hereby give my permission to the physician selected by the Health Services Director and/or Institute President to order X-rays, routine tests, and treatment. In the event that I am incapacitated and my emergency contacts cannot be reached in an emergency, I hereby give my permission to the physician selected by the Health Services Director and/or Institute President to hospitalize, secure proper treatment, and order injections and/or anesthesia and/or surgery.
Financial Deposit of $250
Deposit
Price:
$250.00
Billing Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Total
$0.00
Credit Card
*
American Express
Discover
MasterCard
Visa
Card Number
Month
01
02
03
04
05
06
07
08
09
10
11
12
Year
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
Expiration Date
Security Code
Cardholder Name
NOTE: To avoid the duplicate charges, please press the submit button only once.
Signature