Mailing Address:
The Potter's Institute
c/o The Potter's House
6777 West Kiest Boulevard
Dallas, Texas 75236
Admissions Office:
Hours: Tuesday - Friday
10:00am-4:00 pm
PH: 214-333-6507
FX: 214-333-6512
Email:
tpinst@tdjakes.org
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Returning 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.
Name
Last First MI
Social Security #
Emergency Contact:
Name
Address
Home Telephone
City
State
ZIP Code
Work Telephone
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
Credit Card Number
Exp. Date
Cardholder Name
(Please Print)
____________________________
Cardholder's Signature
(Not valid w/o signature)
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