Student Enrollment Form Kentucky School of Ministry

A ministry of

The Kentucky District Council of the Assemblies of God

PO Box 98 7206 Clore Lane Crestwood, Kentucky 40014 Stan Holder, Director Phone: 502-241-7111 Email: ksom@kyag.org Fax: 502-241-7112 Website: www.kyag.org

Name: __________________________ Home phone: ____________________ Address: ________________________ Cell phone: ____________________ City: _________________ Zip: _________ Email: ______________________ Church you attend: ____________________ City: ____________________ Pastor: _________________________

Please indicate below which level of ministry credential you are studying for. _____ Certificate of Ministry _____ Licensed _____ Ordained ______ Youth Ministry ______ Childrens Ministry _____ I am not studying for credentials

Please return the completed enrollment form and the $25 enrollment fee to the Kentucky District office via postal mail. Upon enrollment students register for classes one at a time. The registration fee for each class session is $60. Email Stan Holder (ksom@kyag.org) or phone the District Office (502-241-7111) for class schedules, registration forms, and more information.

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IMPORTANT: My initials here _______ verify my agreement that: 1) I am at least 18 year old, or if I am not at least 18 years old, I understand that I must have an adult accompany me if I choose to stay on the grounds for the school 2) Successful completion of KSOM courses does not guarantee credentialing with the Assemblies of God 3) Prior to class instruction, a thorough self-review of the text is required 4) I will be prepared to turn in my study guide at the start of the class for grading. In addition, I will be sure to have two hard copies of my study guide and bring them me. One to turn in, and one for my own use. 5) My name, photo/video likeness, testimonials, etc. may be used for informational/promotional purposes related to KSOM or the Kentucky District AG without my further consent or remuneration