Child of God Lutheran School
650 Salt Lick Road St. Peter’s, MO 63376
636-970-7080 www.coglcs.org
Application for Admission 2011-2012
Program (Please Check one)
Preschool half day ___
Pre-Kindergarten Half Day ___
Preschool Full Day ______
Grade_______
Pre-Kindergarten Full Day ______
STUDENT INFORMATION (Please Print)
Student Name: ___________________
First
__________________
Middle
______________________
Last
___________________
Nickname
Address: _______________________________ City:_________________________ State _______ Zip: _________
Phone: ____________________________
Gender: _________
Date of Birth: ______________________ SSN: ________________________
Race/ Ethnic Group____________
Language Spoken in the Home:__________________________
Please answer the following questions. (Please print)
Does the family attend church regularly?
Name of Church______________________
Yes
Pastor: ______________________________
No
Sometimes
(circle one please)
Does the student attend Sunday School?
Yes
No
Sometimes
Religious Affiliation:
(circle one please)
Baptized: Yes No
Baptism Date___________
School District in which you live: _____________________
Current School attending: __________________________
School District:________________________
Grade Level: __________
Dates Attended:_____________________________
Previous Schools attended:
Current School attending: ___________________________
School District:________________________
Grade Level: __________
Dates Attended:_____________________________
Previous Schools attended:
Current School attending: ___________________________
School District:________________________
Grade Level: __________
Dates Attended:_____________________________
Does the Student have a diagnosed disability?
_____ Yes ________ NO
If yes, please list ________________________
Does the student have an Individualized Education Plan
(IEP)? ____ Yes ____ No
If yes, please include a copy with this form)
Are there any restrictions, which would limit or exclude your
child’s full participation in P.E. Class?
Does the child take any medication on a regular basis?
_____Yes ____ No
___ Yes ____ No
If yes, please explain
Name of Medication _____________________
Please list the Public school child would attend:
________________________________
Siblings
Attend Child of God
Name _________________________________Yes_____No____ Birth Date _____________________________________
_________________________________Yes_____No____
Birth Date _____________________________________
_________________________________Yes_____No____
Birth Date _____________________________________
_________________________________Yes_____No____
Birth Date _____________________________________
Online form
FAMILY INFORMATION
Student Lives with (please check all that apply)
_____ Both Parents ____ Mother ____ Father ____ Grandparents _____Guardian
Parents Marital Status: Married
Widowed
Separated
Divorced
Other : _________________
(circle one please)
If divorced/separated, who has legal custody? ________________________________
Parent/ Guardian Information
Name:
Home Address:
City, State, Zip:
Relationship to Student:
Home Phone:
Work phone:
Cell Phone:
Occupation:
Employer:
E-mail address:
Parent/ Guardian Information
Name:
Home Address:
City, State, Zip:
Relationship to Student:
Home Phone:
Work phone:
Cell Phone:
Occupation:
Employer:
E-mail address:
I/We ___________________________________________________ hereby give consent to Child of God Lutheran School
and its administration to use and/or include photographs, video, stills, slides, of my child or family as part of the school’s
marketing program. This may be in, but limited to newsletters, bulletin boards programs, flyers, brochures, on its website, etc.
Names will not be used by the school without specific permission and is granted in writing. It is not the intent of the school or
its administration to profit from such use.
I/We are aware that while the school and its administration will make every effort for good use of such, we cannot be held
responsible for what a third party may do with the posting of pictures by the school. Initials ____________
I/We agree to allow our name, address, and phone information to be included in the school directory, which is printed each
year by the school, for use by faculty, staff, parents and administration of the school. This information is not given or sold to
anyone outside of the school and its’ administration.
Signed _________________________________________________ Date ____________________________
* If you were referred by another parent please fill out referral form from office. *
Office Use Only
Registration Fee $_____________________ Check Number __________________________________
Date Accepted ________________________ Time Accepted ___________________________________
Copy of Report Card/ Records: ____________________ Copy of Birth Certificate (PK, KG)
Principal interview: _________________________
Accepted: ___Yes ___ NO ___ Conditional
Notes:
REV. 2/6/2016