EmailMe Form - Student Enrollment Form

Please mark which campus you are attending

Name *

Prefix First Last Suffix

Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Date of Birth *

Marital Status

Gender

Male

Female

Email Address

Phone

### - ### - ####

Cell

### - ### - ####

Do You Have Credentials for Ministry? *

No

Yes, Ordained Minister

Yes, Licensed Minister

If Yes, What church do you hold credentials with?

Information on Previous Education

List all schools attended (Including High School and credits and/or Degrees

Institution #1 (Name,Location, Years Attended, Degree Earned)

Please have copies of High School Diploma, or GED or official transcripts for all colleges attended sent to school Registrar

Institution #2 (Name,Location, Years Attended, Degree Earned)

Please have copies of High School Diploma, or GED or official transcripts for all colleges attended sent to school Registrar

Institution #3 (Name, Location, Years Attended, Degree Earned)

Please have copies of High School Diploma, or GED or official transcripts for all colleges attended sent to school Registrar

Program Selection

Please check one course of study

Undergraduate

Associate in Biblical Studies

Bachelor in Biblical Studies

Bachelor of Pastorial Ministry

Bachelor of Religious Education

Bachelor of Christian Counseling

Masters

Doctors

Doctor of Religious Education

Doctor of Philosophy in Christian Thought

Doctor of Philosophy in Christian Counseling

Doctor of Philosophy in Pastoral Counseling

Doctor of Philosophy in Christian Marriage & Family Counseling

Doctor of Ministry

Doctor of Theology

Credit Card Information

Please fill out credit card information below

Credit Card *

Exact Name on Credit Card *

Credit Number *

Expiration Date *

CV Number *

The 3 or 4 digit code on back of card