Peace River Bible Institute

* First and Last Name:

* Mailing Address:

* City:

* Province:

* Postal Code:

* Home Phone: ( ) -

Mobile Phone: ( ) -

* Primary Phone Number (which number are we most likely to reach you at?)

* Email Address

* High School Grade

* High School Graduation Year

* Did someone invite you for a campus visit?

* What was the student's name?

* Current age:

* Gender:

* Emergency Contact Name & Phone Number

* Which date would you like to visit?

If you selected other, please specify on which date you would like to visit:

Campus Visit