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STUDENT INFORMATION:
For returning students: only name, signature and changes are necessary.
STUDENT'S NAME*
GRADE LEVEL* Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade
DATE OF BIRTH* January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901
DATE OF BAPTISM January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901
SOCIAL SECURITY #
Asian
Black/African
Caucasian
Hispanic/Latino
Native American
Pacific Islander
Other
(select all that apply)
SIBLINGS
Please include: First and Last name, Grade Level
PARENT/GUARDIAN INFORMATION:
FATHER*
CELL #*( ) -
, AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
EMAIL*
PLACE OF EMPLOYMENT
WORK #( ) -
MOTHER*
If different from Father's address.
EMAIL
CHURCH MEMBERSHIP
EMERGENCY NUMBERS:
These contacts would be used if mom or dad where unreachable in an emergency.
EMERGENCY CONTACT 1
PHONE #( ) -
EMERGENCY CONTACT 2
EMERGENCY CONTACT 3
AUTHORIZED PICK UP CONTACTS:
People authorized to pick up your student(s).
NAME*
PHONE #*( ) -
NAME
PUBLICITY PERMISSION:
Publicity permission includes:
Newspaper, Immanuel Website, Facebook, Screens in Church, etc.
YES
NO
We love to recognize and encourage students for awards and accomplishments. May we publish your child's picture in the newspaper and include their name?
May we use your child's picture without his/her name on our school website/online media platforms?
AGREEMENT OF TERMS
By typing my name below:
I understand that the information on this form is correct to the best of my knowledge.
I understand the Registration Fee in non-refundable.
*
By checking this box, I give my permission to use this as my digital signature to this form.
