ENROLLMENT APPLICATION 2017 - 2018 First Lutheran School 1104 N. 4th St., Ponca City, OK 74601 580-762-9950 - FAX 580-762-4243 e-mail: lutheransecretary@yahoo.com
www.flcspc.com
Parent Information (If parents are separated, please list custodial parent first) □ Parent □ Guardian □ Step-parent □ Grandparent □ Parent or □ Guardian □ Step-parent □ Grandparent Name Name Home Address, City, State and Zip (or □ same)
Home Address, City, State and Zip Home Phone
Cell Phone
Home Phone
Cell Phone
Employer Name
Employer Name
Employer Phone
Employer Phone
Does employer have a matching gift program □ yes □ no □ Married □ Divorced □ Separated □ Remarried □ Widowed □ Single
Does employer have a matching gift program □ yes □ no □ Married □ Divorced □ Separated □ Remarried □ Widowed □ Single
Has this student, or any other children in your household, previously been enrolled at First Lutheran? □ Yes □ No Referred to First Lutheran School by a current school family? List their name here:
Students Information Name: Enrolling in Grade: SSN:
Gender
Birthdate:
□ Male □ Female
Baptism date:
□Hispanic □Non-Hispanic Race: □Caucasian □African American □American Indian □Asian □Two or more Races
Student's previous school name, address, and city: Name: Enrolling in Grade: SSN:
Gender
Birthdate:
□ Male □ Female
Baptism date:
□Hispanic □Non-Hispanic Race: □Caucasian □African American □American Indian □Asian □Two or more Races
Student's previous school name, address, and city: Name: Enrolling in Grade: SSN:
Gender
Birthdate:
□ Male □ Female
Baptism date:
□Hispanic □Non-Hispanic Race: □Caucasian □African American □American Indian □Asian □Two or more Races
Student's previous school name, address, and city: Name: Enrolling in Grade: SSN:
Gender
Birthdate:
□ Male □ Female
Baptism date:
□Hispanic □Non-Hispanic Race: □Caucasian □African American □American Indian □Asian □Two or more Races
Student's previous school name, address, and city: Students Live With: o Both Parents o Mother o Father o Guardian Shared custody between parents
Student Allergies to foods or medicines? Please list which student & allergy here:
Family Information Brother (s) & Sister (s) names (other than listed above)
Age
Grade
School Attending
Emergency/Pick-Up Information Person(s) to contact in emergency if parents cannot be reached: Relationship First: To Student: Relationship Second:
To Student:
Phone: Phone:
Relationship Third:
To Student:
Phone:
Doctor:
Phone:
Purpose of Enrollment Why are you considering our school? How did you hear about our school?
Educational Background Please answer the following questions. Circle Y or N. Has student repeated a grade? Part of a Special Learning Program? Participated in a Gifted Program? Had Learning Difficulties in Reading? Experienced Discipline Problems? Please comment about any of your responses:
Y or N Y or N Y or N Y or N Y or N
Received Tutoring? Currently on Medication? Received Honors/Awards?
Experienced difficulties in Math? Ever Suspended?
Y or N Y or N Y or N Y or N Y or N
Family attends Church? □ Yes □ No Where? First Lutheran is interested in the spiritual welfare of the entire family of students of our school. We would be most happy to serve you also. May we invite you to attend an adult class of Biblical information? □ Yes □ No, thank you
Payment Information Payment Plan: Member One Payment Two Payment 9 months 12 months (You will be placed in the 9-month plan if you do not indicate your preference.) To reserve a place, please return this application with the enrollment fee to the school as soon as possible. (Enrollment will open to the public on March 1.) A minimum of 1/3 is required to hold your place. You will be notified of our registration date in August. At that time, students new to First Lutheran will be required to have immunization records and a copy of their birth certificate. Signature:
Date:
By signing you agree to the terms stated above.
School Records Requested:______ SS Card:______
School Records Received:______
Birth Certificate:______
Shot Records:______