ST. JOHN'S LUTHERAN SCHOOL ENROLLMENT FORM

 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) 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. John’s
Lutheran School as specified in the Parent Handbook and as updated in the school’s
weekly newsletter.

II. I / We desire for our child an education which will include the study of God’s 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 school’s 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 child’s 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 child’s 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: ______________________________