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