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 25-26

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 25-26

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 25-26

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

Yes

No

Parents *

Which of the following teaching options will work for you?

Weekly

Bi-Weekly

Substitute

None of the above