Advent Evangelical Lutheran Church

A member congregation of
The Lutheran Church - Missouri Synod
(317) 873-6318

 

 

ADVENT LUTHERAN PRESCHOOL

( Personal Data Registration Form - Confidential)

 

Child's Name     Class Preference 

Age     Date of Birth    Birthplace City and State 

Mother's Name    Occupation 

Father's Name     Occupation 

Street Address    City State Zip 

Home Telephone    Email Address  

Mother's Work Telephone    Mother's Cell Telephone 

Father's Work Telephone     Father's Cell Telephone  

Parent's Marital Status  MarriedSeperatedDivorcedOther If Seperated/Divorced, Child lives with 

Alternate persons to contact in cased of an emergency

Name    Relationship     Telephone 

Name    Relationship     Telephone 

List other children in family (name, age, grade)

       

   

Family Church    Pastor's Name 

Child's Baptismal Date 

Advent Lutheran Preschool

Student Health Record

Immunization record (may email record from physician to dtrewartha@adventlutheran.org or fax to 873-6369)

List Dates of:                First                              Second                             Third                              Booster

DPT                      

Oral Polio             

Hib                        

MMR                     

Hep B                   

Rotavirus              

Varicella               

Pneumococcal    

List all allergies and special precautions or treatments indicated:

 

List any medications currently being administered to child:

 

List any physical or developmental disabilities and special needs indicated:

 

List any diseases the child has had (chicken pox, etc.)

 

Physician's name   

Address    Telephone