2024 St. Peter's Lutheran School - Student Enrollment Form

Student Enrollment Form

General Information
Operation's Name*
Director's Name*
Date of Admission*
Date of Withdrawal*
Child's Name*

First NameLast Name
Child Lives With*

Both ParentsMomDadGuardian
Child's Birth Date*

MonthDayYear
Child's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent 1*
Parent 2*
Guardian's Name
Parent/Guardian Address (if different from the child's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother's Telephone Number*

Area CodePhone Number
Father's Telephone Number*

Area CodePhone Number
Guardian's Telephone Number

Area CodePhone Number
Email*
example@example.com
Emergency Contact (if parent/guardian can not be reached)*

First NameLast Name
Emergency Contact Relationship*
Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Phone Number*

Area CodePhone Number

Authorized Pick-Up

I authorize the child care operation to release my child to leave the child care operation ONLY with the following persons. Please list name and telephone number for each. Children will only be released to a parent or guardian or to a person designated by the parent/guardian after verification of ID.
Contact (1)*

First NameLast Name
Phone Number*

Area CodePhone Number
Contact (2)

First NameLast Name
Phone Number

Area CodePhone Number
Contact (3)

First NameLast Name
Phone Number

Area CodePhone Number
Additional Comments

Authorization for Emergency Medical Attention

In the event that I cannot be reached to make arrangements for emergency medical care, I authorize the person in charge to take my child to:
Name of Physician*
Physician Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Emergency Medical Care Facility*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I give consent for the facility to secure any and all necessary emergency medical care for my child.
Signature*

Clear

Additional Information
List any special problems that your child may have such as allergies, existing illness, previous serious illness, injuries and hospitalizations during the past 12 months, any medication prescribed for long-term continuous use, limitations or restrictions on activities, reasonable modifications of accommodations, adaptive equipment, and any other information which caregiver's should be aware of. If none, type NA.*
Child daycare operations are public accommodations under the Americans with Disabilities Act (ADA), Title III. If you believe that such an operation may be practicing discrimination in violation of Title III, you may call the ADA information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY).
Does your child have diagnosed food allergies?*

YesNo
Allergy plan submitted on:
Date
Parent/ Guardian Signature *

Clear

Admission Requirement
If your child does not attend pre-kindergarten or school away from the child care operation, one of the following must be presented when your child is admitted to the child care operation or within one week of admission. Check only ONE option:*

A signed and dated copy of a health care professional's statement will be submitted to the childcare facility.Medical diagnosis and treatment conflict with the tenets and practices of a recognized religious organization, which I adhere to or am a member of. I have attached a signed and dated affidavit stating this.My child has been examined within the past year by a health care professional and is able to participate in the day care program. Within 12 months of admission, I will obtain a health care professional's signed statement and submit it to the child care operation.
Name of Health Care Professional (if different from above)

First NameLast Name
Address of Health Care Professional (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Signature*

Clear

Financial Contract
Registration Fee is $110 annually ($165 for siblings).

Tuition is invoiced monthly for nine months (September – May) or by semester (Fall and Spring).

Tuition is due on or before the 1st of the month. A late penalty of $15.00 will be charged on a past due balance after 5 business days. A student may not be allowed to continue enrollment if there is a past due balance that continues without notification of reason.

Daily Late Charge is $5.00 if student is picked up after dismissal time.

Insufficient Check Charge is $22.00.

A $15 Administration fee will be added to the September and January invoices to help cover processing fees.

A waiver of the above charges in unusual and meritorious circumstances can be made with the written approval of the director and the school board.

St. Peter’s Lutheran Church generously provides our school with facilities, utilities, secretarial support, and custodial support. The congregation values the school as an important part of its ministry in the community. However, of necessity, all salaries and current operating expenses must be met monthly by tuition and registration fees. We appreciate your timely consideration of fees. If circumstances prevent you from paying tuition on time, contact the director so the school can work with you without penalty.
I would like to be invoiced*

Monthly (September-May)Semester (Fall and Spring)
Signature*

Clear
Uploads

You must upload the following required documents or submit a copy to the childcare operation before admission.
Vaccine Record/Exemption Affidavit

Browse Files

Cancelof
Health Statement from Medical Professional

Browse Files

Cancelof
Should be Empty:

Student Enrollment Form

Consent Information

Authorized Pick-Up

Authorization for Emergency Medical Attention

Additional Information

Admission Requirement

Financial Contract

Uploads