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Grace Lutheran Church

Sunday School Registration 2009-2010

Student Information
Student Name (Last, First Middle)
Student Address
Parent(Father)/Guardian Name
Parent(Father)/Guardian Address (if different than students)
Parent(Father)/Guardian Home and Cell Phone Numbers
Parent(Father)/Guardian Email
Parent(Mother)/Guardian Name
Parent(Mother)/Guardian Address (if different than students)
Parent(Mother)/Guardian Home and Cell Phone Numbers
Parent(Mother)/Guardian Email
Please select the address where mailings should be sent	StudentParent(Father)/GuardianParent(Mother)/Guardian
Student Date of Birth
Date of Baptism
Gender	Male Female
Grade Level in School (2009/10)	Pre-KK123456789101112
Is this student a member of Grace Lutheran Church?	Yes No
If no, name of the church he/she does belong to
Can your child’s likeness (photo or video) be used within the church for Sunday School promotional pieces?	Yes No
Preschool, school or day care student attends
Emergency Information
Doctor's Name
Doctor's Phone
Dentist's Name
Dentist's Phone
If emergency treatment is required and a parent or guardian cannot be reached immediately, may the Church authorities use their judgment in calling the doctor or dentist named above?	Yes No
If the above doctor or dentist is not available, do you give the Church officials the authority to seek treatment from another doctor or dentist?	Yes No
If your answer is NO to either question, what does the parent/guardian want done in case of an emergency?
Current Health/Educational Information
Please check Yes or No for each item. If you have more specific information on any condition please note below.
ADD or ADHD	Yes No
Allergies	Yes No
If YES, please specify (insect bites, medication, and dietary restrictions)
Diabetes	Yes No
If yes, insulin dependent?	Yes No
If yes, when?
Asthma	Yes No
If yes, is an inhaler used?	Yes No
If yes, when?
Epilepsy or Seizures	Yes No
Does the student wear eyeglasses or contacts?	NoneEyeglassesContacts
Please describe more details on any of the above conditions or any other physical limitations or disabilities of the student.
Please explain any special learning needs the student may have
Please indicate if the student is in any special learning classes.
Name of person completing this form
Email Address to use as confirmation for filling out this form
Image Verification Please enter the text from the image: [ Refresh Image ] [ What's This? ]
html form NOTE: Please print this page before choosing "Submit", if you would like a copy of this form. An email confirmation with your information will be sent to the email address you entered.