Immanuel Lutheran School Gaylord

& Shining Stars Learning Center

New Registration Form

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If you would rather not submit your registration using this secure form then you can download and print out the student registration pdf below. Print it out and submit it personally or by email by July, 1 2019.

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    * Denotes a required field

    Student Information

    Student Name:*

    (First)

     

    (Middle)

     

    (Last)

    Grade:*


    Date of Birth:*

    Baptism Date:*

    Church Membership:*


    Mothers Contact Information

    Mothers Name:*

    Email:*


    Address:*


    City:*

    State:*

    Zip:*


    Home Phone:*

    Mobile Phone:*

    Place of Work:*

    Work Phone:*


    Fathers Contact Information

    (If different than above)

    Fathers Name:*

    Email:*


    Address: (If different than above)


    City:

    State:

    Zip:


    Home Phone:

    Mobile Phone:*

    Place of Work:*

    Work Phone:*


    Medical Contact Information

    Physician:*

    Dentist:*


    Physicians Phone Number:*

    Dentists Phone Number:*


    Physicians Address:*

    Dentists Address:*


    Emergency Contact Information

    Emergency Contact #1:*

    Relation:*

    Phone:*


    Emergency Contact #2:*

    Relation:*

    Phone:*


    Persons Not Authorized to pick up child

    Person 1:

    Person 2:


    Daycare Contact Information

    Name:

    Contact:


    Address:

    Phone:




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