Good Shepherd Lutheran School
New Student Registration
Student Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Place of Birth
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Grade Applying for
*
Please Select
Kindergarten
1st
2nd
3rd
4th
5th
Siblings at this School or Trinity Lutheran Preschool
*
Yes
No
Siblings Name
First Name
Last Name
Siblings Name
First Name
Last Name
Siblings Name
First Name
Last Name
Student lives with
*
Please Select
Both Parents
Mother Only
Father Only
Guardian
Other
Parents are
*
living together
divorced
separated
Joint custody agreement
Student is adopted
*
Yes
No
If so, does the student know?
Student is baptized
*
Yes
No
Are you interested in:
*
Learning about Lutheranism
A call by our pastor
Having someone baptized
I am not interested in any of the above
Previous School Attended
*
Ex: Trinity Lutheran Preschool
Explain any physical or mental factors which might affect your child's progress
*
Has your student been diagnosed with ADD/ADHD? If so, what is the current treatment
*
Does your child have an IEP or 504?
*
List any allergies or food restrictions
*
Guardian Information
Guardian-1 Name
*
First Name
Last Name
Relationship to Student
*
Ex: Mother
Gender
*
Male
Female
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
*
Church Name
Guardian-2 Name
First Name
Last Name
Relationship to Student
Ex: Mother
Gender
Male
Female
Prefer Not to Say
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Church Name
Persons Authorized to Pick-up Student
Name
First Name
Last Name
Relationship to student
Phone Number
Please enter a valid phone number.
Name
First Name
Last Name
Relationship to student
Phone Number
Please enter a valid phone number.
Name
First Name
Last Name
Relationship to student
Phone Number
Please enter a valid phone number.
Name
First Name
Last Name
Relationship to student
Phone Number
Please enter a valid phone number.
Auto-Withdrawal Payment Plan
Please select one
*
1 payment by August 1
10 payments (Aug-May)
12 payments (Aug-July)
Person(s) responsible for account:
*
First Name
Last Name
First Name
Last Name
Terms of Agreement
My child and I will follow school policies and cooperate with the education program at Good Shepherd. Initial below.
*
I will pay fees when due and late fees that are accrued. Initial below.
*
I realize that withdrawal may be required for accounts in arrears. Initial below.
*
I understand that the registration fee is non-refundable. Initial below.
*
I grant permission for my child to be transported in case of emergency.
*
Yes
No
Initial here.
*
I hereby give permission for video, photo, and camera images of my child to be used solely for the purposes of Good Shepherd Lutheran School’s promotional materials, publications, social media and website. I waive any rights of compensation or ownership thereto.
*
Yes
No
Initial here.
*
Parent /Guardian Consent for Medical Treatment
As the parent or legal guardian, I hereby consent to Good Shepherd Lutheran School to provide emergency medical or dental care prescribed by a duly licensed physician (M.D) or dentist (D.D.S) for my dependent child. This care may be given under whatever conditions necessary to preserve the life, limb, or well being of my dependent child.
Guardian Name
First Name
Last Name
Signature
Date
-
Month
-
Day
Year
Date
For office use only:
Document Verified by:
First Name
Last Name
Signature
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