St. John's Lutheran Preschool Application

St. John's Lutheran Preschool Application
Please fill out and submit one application per child enrolling in preschool.
Please check one*

PK 2/3 - 3-Day ClassPK 3/4 - 3-Day ClassK-Prep - 5-Day Class
Child's Full Name*

First NameMiddle NameLast Name
Child's Nickname
MaleFemale
Child's D.O.B*

MonthDayYear
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone

Area CodePhone Number
Preferred E-Mail*
Alternate E-Mail
Father's Name*

First NameLast Name
Occupation
Work Phone

Area CodePhone Number
Cell Phone *

Area CodePhone Number
Mother's Name*

First NameLast Name
Occupation
Work Phone

Area CodePhone Number
Cell Phone *

Area CodePhone Number
Church your family attends*
Has your child been baptized?*

YesNo
List name, relationship and age of those living with child*
Has your child attended daycare or preschool?*

YesNo
How did you learn about our preschool?

InternetPreschool Sign/BannerFriend or RelativeOther
Emergency Contact Name

First NameLast Name
Relationship to Child
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Authorization to Consent for Treatment of a Minor

I/We, the undersigned, parents of the child named above, do hereby authorize St. John's Lutheran Preschool as agent for the undersigned to consent to any emergency x-ray, examination, anesthetic, medical or surgical diagnosis of treatment and hospital care, which is deemed advisable by, and is to be licensed under the provisions of the medical practical act on the medical staff of a licensed hospital, whether such diagnosis of treatment is rendered at the office of said physician or said hospital. It is understood that this authorization is give in advance of any specific consent to any and all such diagnosis, treatment of hospital care, which to aforementioned physician in exercise of his/her best judgment may deem advisable.
Photos/Videos

Be advised that sometimes we use pictures/videos from our classroom for our website, social media and other promotional purposes. At no time will a child be identified by name.
FILLING YOUR NAME HERE CONSTITUTES YOUR SIGNATURE*

First NameLast Name
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