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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