Certificate Course
Enrollent Form

1. DELIVERY SYSTEM

NOTE: If you want to take more than one course and want to choose a different delivery system, you will need to fill out the form for each course type. Otherwise you can enroll in as many courses as you want in the same delivery system.

Please select how you will take your Course(s):

Digital Course

2. PERSONAL INFORMATION

First Name:  
Middle Initial:  
Last Name:  
Address:  
City:  
State:  
Zip Code:  
Email:  

 
Home Phone:  
Cell Phone:  

3. CHURCH INFORMATION

Church ID# (IA067 if online or digital):  
Church Name (studying at):  
Church City:  
Church State:  
Your Group Leader:  

4. COURSE INFORMATION

All courses below are two credit hours. Check the Course(s) in which you are enrolling:  
Check the "Physcial Textbook" box if you would like to add a hard copy book for $45 (shipping included).

Check the "Married Student Discount" for $9.50 if your spouse is taking the same course and provide spouse's name below.



Your spouse's name (if applicable):

 

5. COSTS FOR COURSE(S)

Payment is due in full at time of enrollment



6. SIGNATURE

By signing below I agree to the following:

  • I authorize the group leader named above to receive my academic records for this course.
  • I have read and comply with the Code of Conduct as found in the Catalog and the Student Handbook.
  • I have read the information on the back of this sheet. I understand my rights and obligations.
  • I have received a copy of this form as proof of payment. (church based student only)
  • I understand that whoever paid for this course is entitled to a refund should I withdraw or cancel my enrollment.
Signature:  
Date: