Colorado Institute of Musical Instrument Technology
Phone 303-663-4084
Facsimile 866-628-2824
Email: dparker@ciomit.com
Website: www.ciomit.com
651-300 Topeka Way Application
Castle Rock, CO 80109
P.O. Box 983
Castle Rock, CO 80104-0983

Applicant’s Name: __________________________________________________________
First Middle Last (Preferred Name)
Home Address: __________________________________________________________

City: ______________________________________ State: ________ Zip Code: _______________

Birthdate: __________________ Sex: __________
Social Security #: ____ ___ _____

Father’s Name: __________________________________________________________
(Preferred Name)
Home Address: __________________________________________________________

City: __________________________________________
State: __________________ Zip Code: ____

Home Telephone: ________________________________

Father’s Preferred Email: ______________

Father’s Business & Title: __________________________________________________________

Address: __________________________________________________________

City: __________________________________________

State: __________________

Zip Code: ________________

Business Telephone: _______________________________________________________

Cell: _______
This application is for ____/____/ 20 ___ - ____/____/20____

Current School: __________________________________________________________

Current School Address: __________________________________________________________

City: __________________________________________
State: __________________ Zip Code: _____

Principal: ______________________________________ School Telephone: _____________________

Email: _________________________________________ School Facsimile: _______________________
APPLICATION FOR ADMISSION
Photograph

Mother’s Name: __________________________________________________________
(Preferred Name)

Home Address: __________________________________________________________

City: __________________________________________
State: __________________ Zip Code: _____

Home Telephone: ________________________________
Mother’s Preferred Email: _______________

Mother’s Business & Title: __________________________________________________________
Address: __________________________________________________________

City: __________________________________________
State: __________________ Zip Code: _____

Business Telephone: _______________________________________________________ Cell: _______

Names/Addresses of two references. (Please ask each reference to submit a letter of recommendation. )
1. __________________________________________________________
__________________________________________________________
2. __________________________________________________________
__________________________________________________________

Applicant’s academic interests/talents: ________________________________________________________
________________________________________________________

Applicant’s extracurricular interests/talents: _________________________________________________________
_________________________________________________________
_________________________________________________________

Has the applicant included the $75.00 application fee? _______________

The signatures below certify that the applicant is of good character, and that in making application, he/she agrees to uphold CIOMIT School’s Honor Code and to abide by the Standards for CIOMIT School Students as they are outlined in the Student Handbook.

Applicant: ________________________________________

Date:_____________________________________________

CIOMIT
Phone 303-663-4084
Facsimile 866-628-2824
Email: dparker@ciomit.com
Website: www.ciomit.com
651-300 Topeka Way
Castle Rock, CO 80109
P.O. Box 983
Castle Rock, CO 80104-0983

CIOMIT School admits students of any race, color, national or 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, national or ethnic origin in the administration of its educational policies, admissions practices, and athletic and other school-administered programs.