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Preschool Registration Information

Registration for 2005/2006 opens Tuesday January 18, 2005. For more information, or to obtain a registration form, please call the church office at (317) 873-6318. To enroll, please submit the registration form, along with a non-refundable registration fee of $50.00

(Back to Preschool Main Page) 

Date ______________						(Office Use)

School Year _______					_____	____________
						Class	Registration
Class Pref: _______						Paid

ADVENT LUTHERAN PRESCHOOL
(Personal Data Registration Form -- Confidential)

Child's Name __________________________________________Nickname_____________

Age _____ Date of Birth __/__/__Birthplace (City/State) ____________________

Address (Street, City & Zip Code) __________________________________________

____________________________________________________________________________

Home Telephone ____-____-_____ 	Mother's Work/Cell Telephone ____-____-_____

Father's Work Telephone ____-____-_____	Father's Cell Telephone ___-___-____

Mother's Name _________________________ Occupation _________________________

Father's Name _________________________ Occupation _________________________

Are parent's separated or divorced? ____ If yes, child lives with? _________

Alternate persons to contact in case of an emergency:

Name ________________________Relationship____________Telephone ___-___-_____

Name ________________________Relationship____________Telephone ___-___-_____

List other children in the family (Name, age, grade):

___________________________________	____________________________________

___________________________________	____________________________________

Family Church _____________________	Pastor's Name ______________________

Child's Baptismal Date ____________
(Back to Preschool Main Page)

ADVENT LUTHERAN PRESCHOOL
Student Health Record

Immunization record (can attach record from physician):

Date of:	1st		2nd		3rd		Booster


DPT __________     __________      __________       ______________

Oral Polio   __________     __________      __________       ______________

Hib __________     __________      __________       ______________

MMR __________     __________      __________       ______________

Hep B        __________     __________      __________       ______________

Prevnar __________     __________      __________       ______________

Varivax __________     __________      __________       ______________

Tuberculin Test __________  Result __________



List all allergies and special precautions or treatments indicated:





List any medications currently being administered to the child:






List any physical disabilities and history of hospitalization:






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







__________________________________________________________________________
Physician's Name          Address			Telephone
Update - 1/3/2005
© 2005 - Advent Lutheran Church - All Rights Reserved
http://www.adventlutheran.org/presch/s-register.htm