Faith Lutheran Church, PreSchool & AfterSchool (LCMS)

Student Full Name(s) *


Student Nickname(s) *


Street Address *


City, Zip *


Home Phone


Student Date(s) of Birth


Age(s) Today


Gender(s)


Father Name


Father Cell


Father Home Phone (if different)


Father’s Employer


Father’s Work Phone


Mother Name


Mother Cell


Mother Home Phone (if different)


Mother’s Employer


Mother’s Work Phone


Preferred Email Address


Person who referred you to Faith AfterSchool?


School Child(ren) Attends?


Grade


Other Person Authorized to Pick Up Child Name


Other Person Authorized to Pick Up Child Relationship


Other Person Authorized to Pick Up Child Phone 1


Other Person Authorized to Pick Up Child Phone 2


Second Other Person Authorized to Pick Up Child Name


Second Other Person Authorized to Pick Up Child Relationship


Second Other Person Authorized to Pick Up Child Phone 1


Second Other Person Authorized to Pick Up Child Phone 2


Family Doctor & Phone


Family Dentist & Phone


Name of Church you Attend


Other Information? (including allergies or fears...)


Is it okay to use your child's picture in publications/websites affliated with Faith PreSchool?
Yes
No