Preschool Registration Form - Immanuel Lutheran Church & School

Child's Last Name *

Child's First Name *

Middle Name *

Date of Birth *

Street *

City *

Zip Code *

Primary Email *

Primary Phone *

Gender *

Class First Choice * Class First Choice

Class Second Choice * Class Second Choice

Mother's Name: *

Cell Number: *

Home Church: *

Father's Name: *

Cell Number: *

Home Church: *

Are you a returning family, or do you currently have children at Immanuel, Preschool-8th grade? *

Yes

No

Please list any school or childcare your child has previously attended:

Has your child ever received services for speech, occupation therapy, developmental delays or other needs? *

Yes

No

If yes, please explain and note location:

Admission Policy: Immanuel Lutheran School admits students of any race, sex, color, national and ethnic origin to all the rights and privileges, programs and activities generally accorded or made available to students at the school. It does not discriminate on the basis of race, sex, color, national or ethnic origin in administration of its education policies and athletic or other school administered programs. Please type your full name and date in the box below (this serves as your signature): *