Mailing Address:
The Potter's Institute
c/o The Potter's House
6777 West Kiest Boulevard
Dallas, Texas 75236
 Email:  tpinst@tdjakes.org 		 Admissions Office:
Hours: Tuesday - Friday 
          10:00am-4:00pm
PH:  214-333-6507
FX:  214-333-6512
                                  Home

     
New Student Registration
    
Part I:  Personal Information
Information will be used for data purposes only and will not affect or influence admission or volunteer opportunities with the Christian Education Department/The Potter's Institute.
    

  Name  Last              First             MI

  Street Address (include apartment number, if any)

  City
State
  Zip Code

  Work Phone
  Home Phone
FAX
E-mail
   
Required Information
Date of Birth: -- mm/dd/yy Gender: Male  Female
SSAN:
Ethnicity: African American  Asian American  Caucasian Hispanic  Other  
The Potter's Institute does not discriminate on the basis of
gender,  race or country of national origin.

Date of Conversion:

 -- mm/dd/yy
Church Membership:   (Name of Church)
Education: High School  College-Degree Earned School:
  
Emergency Contact:

 Name

Address
 Work Telephone
 Home Telephone

  City
State
  Zip Code

  

Referred By:
Name
   
Part II:  Semester

             
Fall I    Winter I Spring I
Fall II Winter II  Spring II
 Section/Course # Course Title Day(s)
   
   

FOR OFFICE USE ONLY

REG. FEE TUITION FEE PAID PAYMENT METHOD DISK/PHOTO#
Part III:  Method of Payment
  
Cash  Money Order Check-Driver's License Number
Visa   MasterCard    American Express
   Amount
Required if using a credit card:

Credit Card Number
   Exp. Date

 Cardholder Name
  (Please Print)		 ____________________________
 Cardholder's Signature 
(Not valid w/o signature)