United Lutheran

1. Student #1 Name *

First Name

Last Name

2. Date of Birth (Student #1)

MM

DD

YYYY

3. Grade Level (Student #1) for 23-24

Preschool

Kindergarten

1st Grade

2nd Grade

3rd Grade

4th Grade

5th Grade

6th Grade

5. Do you have another student to register?

Yes

No (Skip to question 15)

6. Student #2 Name

First Name

Last Name

7. Date of Birth (Student #2)

MM

DD

YYYY

8. Grade Level (Student #2) for 23-24

Preschool

Kindergarten

1st Grade

2nd Grade

3rd Grade

4th Grade

5th Grade

6th Grade

10. Do you have another student to register?

Yes

No (Skip to Question 15)

11. Student #3 Name

First Name

Last Name

12. Date of Birth (Student #3)

MM

DD

YYYY

13. Grade Level (Student #3) for 23-24

Preschool

Kindergarten

1st Grade

2nd Grade

3rd Grade

4th Grade

5th Grade

6th Grade

15. Name of Parent/Guardian enrolling student(s)

First Name

Last Name

19. Phone

(###)

###

####

20. Are you a member of United Lutheran

Yes

No

21. If not, are you interested in receiving information about becoming a member?

Yes

No

22. Emergency Contact Name

First Name

Last Name

23. Emergency Contact Phone

(###)

###

####

25. Does your child need bus transportation on Wednesdays to Youth Group after school?

Bus transportation is available to those who ride Cavalier School buses # 1, 2 & 4.

Yes

No

26. If your child does not ride the bus, will they need transportation to youth group?

Yes

No

28. Do we have permission to use your student's image on social media, website, newsletter, etc?

Yes

No

Parents *

Can you teach Wednesday school bi-weekly this year?

Yes

No