STUDY CENTER STUDENT REGISTRATION FORM

                                                                        (PLEASE PRINT LEGIBLY)

NAME__________________________________                                PROGRAM OF STUDY (PLEASE CHECK ONE)

ADDRESS_______________________________                               __MINISTERIAL STUDIES DIPLOMA

CITY___________STATE________ ZIP_______                                            __CERTIFIED MINISTER LEVEL

PHONE _________________________(HOME)                                             __LICENSED MINISTER LEVEL

PHONE_________________________(WORK)                                             __ORDAINED MINISTER LEVEL

EMAIL_________________________________                                __SPECIALIZED MINISTRIES DIPLOMA

BIRTHDAY____/_____/_____MALE / FEMALE                                            __EDUCATION

SOCIAL SECURITY NUMBER_____________                                             __CHILDREN

(NOTE: THESE RECORDS ARE KEPT                                                           __YOUTH

CONFIDENTIAL.  YOU WILL RECEIVE A                                                   __SENIOR ADULT

STUDENT I.D.NUMBER DIFFERENT FROM                                                __MUSIC

YOUR SOCIAL SECURITY NUMBER FOR                                     __BIBLE AND DOCTRINE DIPLOMA

YOUR PROTECTION.  HOWEVER YOUR                                       __URBAN BIBLE TRAINING MINISTERIAL STUDIES

SOC SEC # IS USED AS A VERIFICATION                                    __CONGREGATION MINISTRIES DIPLOMA

WHEN CHECKING ON GRADES.                                                   __SERVICE CERTIFICATE

                                    ACADEMIC RELEASE AUTHORIZATION

I AUTHORIZE STUDY CENTER LEADERSHIP FROM ARTISTS FOR ISRAEL INSTITUTE

BROOKLYN                                                                             NEW YORK

TO REQUEST ACADEMIC INFORMATION FROM MY OFFICIAL STUDENT RECORD WHICH IS KEPT

WITH THE BEREAN SCHOOL OF THE BIBLE IN SPRINGFIELD, MISSOURI UNTIL I CONTACT THE

SCHOOL AND WITHDRAW THIS AUTHORIZATION IN WRITING.

I UNDERSTAND THAT BEREAN SCHOOL OF THE BILBE OFFERS NON-DEGREE COURSES AND THAT

THEY ARE CALCULATED IN CONTINUING EDUCATION UNITS, NOT COLLEGE CREDITS.

_____________________________________                ________________________________

STUDENT SIGNATURE                                                          DATE