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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

e-mail

e-mail

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:______

Enrollment application 2017 18  
Enrollment application 2017 18  
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