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CHRIST LUTHERAN PRESCHOOL

ENROLLMENT FORM

595 Deerpath Dr., Vernon Hills, Illinois (847) 367-5791

 

Please fill in the appropriate information and return with your registration fee of $90 (payable to Christ Lutheran Preschool or CLPS). Thank you.

 Please select your first and second choice (1, 2); (AM: 8:30-11:00);  (PM: 12:00-2:30)

young 3 yr  programs              3 yr. programs               young 4 yr programs               Pre-K programs

(  ) T, Th AM                                (  ) T, Th AM                 (  ) M, T, Th AM                    (  ) M, W, F   AM

(  ) M, W, F AM                            (  ) M, W, F AM                                                              (  ) T, W, Th  AM

(  ) T, Th PM                                   (  ) T, Th PM                                                                  (  ) M, W, F   PM 

(  ) M, W, F PM                               (  ) M, W, F PM                                                            (  ) M -Th       PM  

                                                                                                                                                         (  ) M -Th       AM

                                                                                                                                                          (  ) M – F   AM

                                                                                                                                                       (  ) M – F   PM

Home Phone                           

Child’s name:                                                                       Boy (  )   Girl (  )

                        Last                        First                        MI

Nickname:                                           Birth date:                                         /                                                     /                                                     Current Age                                      

(If to be used here at school)

 

Address:                                                      City:                                                          Zip                                                          

Birthplace:                                                          

Mother’s Name:                                                                  Work phone:                                                        

Father’s Name:                                                                          Work phone:                                                        

Cell phone numbers:                                                                                              

 

Siblings Names & Ages:                                                                                                  

Religious Affiliation                                                                                             

 

EMERGENCY MEDICAL CARE AUTHORIZATION

I authorize emergency treatment and if necessary, permission for my child to be transported to the nearest hospital or doctor. I agree to pay all fees in connection with such treatment or service. My personal doctor and dentist are:

                                                                                                          

Doctor                                          Phone                                          Address

                                                                                                          

Dentist                                         Phone                                          Address

I hereby authorize Christ Lutheran Preschool to photograph/video my child and use the photos for publicity purposes and relinquish my title, rights, and interest in the finished photos or negatives.

Christ Lutheran Preschool and Christ Lutheran Church are not responsible for any cost due to accidental injury, or illness, for any persons, on or off, Christ Lutheran Church property.

Signature                                                              Date                                                                  

 

 

                                                                                                           

Child’s name                                                    Date

 

                                                                        

Parent/Guardian Signature

 

Health Cautions or Food Allergies:                                                                                            

                                                                                                         

 

Please list special needs if any:                                                                                                 

 

                                                                                                         

 

 

PICK-UP AUTHORIZATIONS

 

 

                                                                                                          

Name                                                                          Phone #

                                                                        

Address

                                                                        

Relationship to child

 

 

                                                                                                          

Name                                                                          Phone #

                                                                        

Address

                                                                        

Relationship to child

 

 

                                                                                                          

Name                                                                          Phone #

                                                                        

Address

                                                                        

Relationship to child