Faith Lutheran Church

Student Full Name *


Student Nickname *


Street Address *


City *


State *


Zip Code *


Home Phone *


Date of Birth *


Age *
Choose: 3 4 5

Class
Choose: Preschool 3/4 Prekindergarten

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


Person(s) with whom child lives
Both Mother Father

Email Address


Emergency Contact 1 Name


Emergency Contact 1 Relationship to child


Emergency Contact 1 Phone 1


Emergency Contact 1 Phone 2


Emergency Contact 2 Name


Emergency Contact 2 Relationship to child


Emergency Contact 2 Phone 1


Family Doctor


Doctor Phone


Family Dentist


Dentist Phone


Sibling's Names and Age


Name of Church You Attend


Is your preschooler baptized?
Choose: Yes No

Baptism Date


Other information (including allergies and fears...)


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

Choice of Payment Plan
Choose: One payment for full year in September (5% discount) Two payments, one in Sept and one in January (2% discount) Nine equal payments, Sept through May