Faith Lutheran Church

Student Full Name *


Student Nickname *


Street Address *


City *


State *


Zip Code *


Home Phone *


Date of Birth *


Age *
Choose: 5 6 7 8 9 10 11 12 13

Gender *
Choose Male Female

Father's Name


Father's Cell Phone


Father's Home Phone


Father's Employer


Father's Work Phone


Mother's Name


Mother's Cell Phone


Mother's Home Phone


Mother's Employer


Mother's Work Phone


Preferred Email Address


Who referred you to Faith After School?


School Child Attends
Choose: Southside Elementary Columbus Signature Academy-Lincoln St. Peter's Lutheran School St. Bartholomew Catholic School other

Student Grade
Kindergarten First Second Third Fourth Fifth Sixth

Other Person Authorized to Pick Up Child Name


Other Person Authorized to Pick Up Child Relationship to child


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 to child


Second Other Person Authorized to Pick Up Child Phone 1


Second Other Person Authorized to Pick Up Child Phone 2


Family Doctor


Doctor Phone


Family Dentist


Dentist Phone


Name of Church You Attend


Other information (including allergies and fears...)


Is it okay to use your child's picture in publications/websites affliated with the Afterschool program?
Yes No