Enrollment Form
Basic - Open Bible Credentialing Track

1. PERSONAL INFORMATION

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

Home Phone: 
Cell Phone: 

2. CHURCH INFORMATION

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

3. COURSE INFORMATION

All digital 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):



4. COSTS FOR COURSE(S)

Payment is due in full at time of enrollment



5. 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: