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For School Year
____________________
For Grade _________
Date App. received ________________
Testing Fee _________
Testing
Date ______________________
Tested by _______________
Accepted
___ yes ____ no _____ WL Letter sent __________
Reg.
Fee paid: ______________________________________
THE STUDENT - FAMILY & CHURCH
1) Student
______________________________________________ Sex ___________
Last Name
First Name
M.I.
2) Address _____________________________________________________________
Street
City
Zip
3) Birthdate _____________________ Phone Number __________________________
4) Birthplace ____________________________________________________________
5) Child lives with [ ] Father [ ] Step-father [ ] Other
[ ] Mother [ ] Step-mother [ ] Explain _________________________
6) Fathers Name __________________ Mothers Name ________________________
7) Employer ____ __________________ Employer ____________________________
8) Work Address ___________________ Work Address ________________________
9) Work Phone ____________________ Work Phone __________________________
10) Occupation ____________________ Occupation ____________________________
11) Are there any special custody arrangements of which we should be aware?
_____________________________________________________________________
12) Names of Brothers/Sisters
Age
School Grade
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
13) How did you hear about St. Johns Lutheran?
Friend _____ Family _____ Present School _____
Radio or Newspaper Advertisement _______ Which?
____________________
14) Reasons for applying for enrollment ______________________________________
15) Family Church Membership _____________________________________________
Active ______ Part-time _____ Inactive _____ Pastors
Name _________________
16) Child Baptized? ____________ Date of baptism _______________
Church where baptized
___________________________________________
17) Emergency contacts (if parents cannot be reached):
Name __________________________ Relationship _______ Phone
_________
Doctor ______________________________________ Phone
________________
THE STUDENT PERSONAL
1) Last school attended ________________________________________________
School address ____________________________________________________
Dates of attendance ________________________________________________
2) Reason for leaving _________________________________________________
3) Does your child have any specific education needs (reading, speech, gifted, remedial,
etc.)?
_________________________________________________________________
__________________________________________________________________
4) Does your child have any physical, emotional, psychological needs or limitations
(medications, handicaps)? ____________________________________________
__________________________________________________________________
5) Will any of the above require an adjustment in scheduled curriculum?
Yes _____ No _____
6) Has your child experienced any discipline / conduct problems, school
suspensions, grade retentions, etc.? Yes _____ No _____
7) Does your child have any allergies? Yes _____ No _____ Please explain.
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
THE STUDENT COVENANT & MEDICAL AGREEMENT
I. I / We certify this information to be complete and factual, and agree to fulfill all
financial
obligations. We agree to adhere to the policies and regulations as required by St.
Johns
Lutheran School as specified in the Parent Handbook and as updated in the schools
weekly newsletter.
II. I / We desire for our child an education which will include the study of Gods
Word
and the application of that Word into the daily life of our child. We will, therefore,
support
the school staff to maintain its high academic and citizenship standards. We understand
that all children are expected to participate in weekly chapel services as well as daily
devotions.
III. I / We hereby invest authority in the school to correct our child excluding corporal
punishment when his/her behavior or conduct interferes with learning activities. We
understand that if, for any reason, our child does not conform to the schools
academic
or citizenship standards, his/her enrollment could be terminated.
IV. I / We grant permission for our child to use all of the play equipment and participate
in all the activities of the school, including field trips and athletics.
V. I / We understand that one-tenth of the tuition fee is
due on the first of each month
and is considered late if not received in the office by the tenth of each month, beginning
August 1 and concluding May 1. We understand that a late fee of $20 is assessed if the
tuition is not received on time and a $10 fee is assessed for each check not honored by
the bank. Furthermore, we understand that enrollment may be terminated IF PAYMENT
IS LATE BEYOND THE END OF THE MONTH. We also understand that in the event of
our removal of your child from school for personal reasons that any tuition already paid
is non-refundable.
VI. I / We understand that the staff has full authority concerning promotions, retentions,
and similar concerns.
VII. I / We hereby grant permission for the school to take whatever steps may be necessary
to obtain emergency medical care if warranted. These steps may include, but are not
limited
to, the following: 1) Attempt to contact a parent, guardian, or any person(s) listed on
the
emergency information form completed for us; (2) Attempt to contact the childs
physician,
another physician, an ambulance, or have the child taken to an emergency hospital in the
company of a staff member; 3) Any expenses incurred under number two above, will be
borne by the childs family.
VIII. I / We hereby give consent to treatment and hospital care which is deemed advisable
by,
and is to be rendered under the general or special supervision of any physician and
surgeon
licensed under the provisions of the Medicine Practice Act on the medical staff of any
available medical facility. It is understood that this authorization is given in advance
of any
specific diagnosis, treatment, or hospital care being required, but is given to provide
authority, and power to give specific consent to any and all such diagnosis, treatment, or
hospital care which the aforementioned physician in the exercise of his/her best judgment
may deem advisable.
IX. I/We, as parent(s) of the student applicant, do prayerfully and sincerely give our
pledge and agreement to all items as stated above.
Signature(s): _________________________________________________________
_________________________________________________________
Date: ______________________________ |