Little Disciples of Christ

Enrollment For School Year 2018-2019

INFORMATION ABOUT CHILD:

Child’s Full Name _________________________________Nickname ___________________

Street Address___________________________________ Phone (____ )________________

City______________________ State___________________ Zip_______________

Birth Date___________ Child’s Sex   Male   Female

Child lives with (circle)  Parents   Mother   Father   Guardian(s)

FAMILY INFORMATION:           FATHER OR LEGAL GUARDIAN        MOTHER OR LEGAL GUARDIAN

Name                                       ___________________________      ________________________

Address (if different from child’s) ___________________________ ________________________

City/State/Zip                           ___________________________      ________________________

Cell Phone                               ___________________________      ________________________

E-mail                                       ___________________________      ________________________

Occupation                              ___________________________      ________________________

Place of Employment               ___________________________      ________________________

Marital Status                          ___________________________      ________________________

Is there a step-parent (if yes, name)___________________________   ________________________

Religious Affiliation                  ___________________________      ________________________

Active in Church                     Yes    No                                             Yes    No

Family attends Church and/or Sunday School at: ______________________Regularly? ܆Yes ܆No

Child is baptized? ܆Yes ܆No If no, are you interested in baptism for your child? ܆Yes ܆No

Are you interested in knowing more about Christ Lutheran Church? ܆Yes ܆No

Child’s Brothers and Sisters:

Name_______________________     Age_____ Name________________________Age_____

Name_______________________     Age_____Name________________________Age_____

OTHER INFORMATION:

School(s) Previously Attended by Child (Day Care, Nursery, Preschool)

Name and location of School _____________________________________________

Special Needs/Instructions _______________________________________________

Signature ____________________ Mother or Legal Guardian          Date__________

Signature_____________________ Father or Legal Guardian          Date__________

**Please return with $25.00 registration fee payable by check to “Little Disciples of Christ.”

Mail to:  Marion Schmidt Director - 707 West 3rd Street - Delavan IL 61734

or Call Marion: 1-217-979-2496