Student Application

Student Information

Student Name*

First Middle Last

Gender*

Male

Female

Birthdate*

Month

Day

Year

Grade Applying For*

Preschool 3's

Preschool 4's

Kindergarten

1st Grade

2nd Grade

3rd Grade

4th Grade

5th Grade

6th Grade

7th Grade

8th Grade

School Year Applying For*

New or Returning Student*

New Student

Re-Enrolling Student

Race/Ethnicity*

White

Black or African American

American Indian or Alaska Native

Asian

Native Hawaiian or Pacific Islander

Hispanic or Latino

Middle Eastern or North African

Allergies

Are you registering any additional students?*

Yes

Student Name*

First Middle Last

Gender*

Male

Female

Birthdate*

Month

Day

Year

Grade Applying For*

Preschool 3's

Preschool 4's

Kindergarten

1st Grade

2nd Grade

3rd Grade

4th Grade

5th Grade

6th Grade

7th Grade

8th Grade

New or Returning Student*

New Student

Re-Enrolling Student

Race/Ethnicity*

White

Black or African American

American Indian or Alaska Native

Asian

Native Hawaiian or Pacific Islander

Hispanic or Latino

Middle Eastern or North African

Allergies

Are you registering an additional student?*

Yes

Student Name*

First Middle Last

Gender*

Male

Female

Birthdate*

Month

Day

Year

Grade Applying For*

Preschool 3's

Preschool 4's

Kindergarten

1st Grade

2nd Grade

3rd Grade

4th Grade

5th Grade

6th Grade

7th Grade

8th Grade

New or Returning Student*

New Student

Re-Enrolling Student

Race/Ethnicity*

White

Black or African American

American Indian or Alaska Native

Asian

Native Hawaiian or Pacific Islander

Hispanic or Latino

Middle Eastern or North African

Allergies

Are you registering an additional student?*

Yes

Student Name*

First Middle Last

Gender*

Male

Female

Birthdate*

Month

Day

Year

Grade Applying For*

Preschool 3's

Preschool 4's

Kindergarten

1st Grade

2nd Grade

3rd Grade

4th Grade

5th Grade

6th Grade

7th Grade

8th Grade

New or Returning Student*

New Student

Re-Enrolling Student

Race/Ethnicity*

White

Black or African American

American Indian or Alaska Native

Asian

Native Hawaiian or Pacific Islander

Hispanic or Latino

Middle Eastern or North African

Allergies

Enrolling Parent / Guardian Information

Enrolling Parent / Guardian Name*

First Last

Relationship to Student(s)*

Home Address*

Street Address Address Line 2 City State ZIP Code

Cell Phone*

Home Phone*

Email*

Place of Employment*

Work Phone

Work Address

Street Address Address Line 2 City State ZIP Code

Parent / Guardian Information

Enrolling Parent / Guardian Name*

First Last

Relationship to Student(s)*

Home Address*

Street Address Address Line 2 City State ZIP Code

Cell Phone*

Home Phone*

Email*

Place of Employment*

Work Phone

Work Address

Street Address Address Line 2 City State ZIP Code

I authorize CLS to contact the following person when parent/guardian cannot be reached during an emergency.*

Emergency Contact Name

Phone Number

Relationship

I give permission for my child(ren) to leave CLS with the people listed below. It is the responsibility of the parents to notify the school in writing of any changes. Your child will not be released to anyone not listed below.

Name

Phone Number

Relationship

Is there anyone who should not have contact with your child(ren)?

Yes

Please list their names:*

**If this is a biological parent, we will need a copy of the court order on file. **

Child(ren)'s Medical Information

Doctor Name*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Name of Preferred Hospital*

Does your child have health insurance?*

Yes

Insurance Company*

ID #*

Child(ren)'s Medical Information

Dentist Name*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Does your child have dental insurance?*

Yes

Insurance Company*

ID #*

Permission given to CLS to obtain emergency medical or dental care as my child(ren) might require while under CLS supervision. Agreement to pay all the costs and fees contingent on any emergency medical/dental care and treatment for my child(ren) secured or authorized under this consent. Permission to administer first aid treatment, as needed.*

Yes

If your child(ren) have allergies, please provide any additional information or special instructions.

Church Information

Home Church

Are you an active member?

Yes

Pastor's Name

Church Denomination

Church Address

Street Address City State ZIP Code

Place of Child(ren)'s Baptism

Address

Street Address City State ZIP Code

Why do you desire for your child(ren) to attend Community Lutheran School?*

Are you interested in membership at Immanuel or St. Paul?*

Yes

Already a Member

Please add any information that may be helpful to our pastor.

Are you interested in bus transportation through the Wapsie Valley School District from your house to school?*

Yes

Four year old preschool through 8th grade only. Parents are responsible for making arrangements with Wapsie.

Which services do you need?

Pick-Up

Drop-Off

Is English the primary language spoken in your home?*

Yes

Please list any other languages.

Has your child(ren) attended another school?*

Yes

Please list each school name.

Has your child(ren) repeated any grade in school?*

Yes

Please indicate which child and grade level repeated.

Has your child(ren) been given any educational psychological test?*

Yes

Which child and what test was given?

By whom?

Results?

Has your child(ren) ever been recommended for special services?*

Yes

What type of services?

Has your child(ren) experienced any difficulty in school (health, academic, discipline, etc.)?*

Yes

Please explain:

Permission given to list family contact information in the school directory?*

Yes

Permission given to use your child(ren)'s photo and/or video on the school website, newsletters, yearbook, social media, area newspaper articles, classroom communications, etc.?*

Yes

Permission given for your child(ren) to attend all educational excursions and field trips?*

Yes

Permission given for your child(ren) to use the computer/internet for educational purposes?*

Yes

Permission given to apply sunscreen with UVA and UVB protection of SPF15 or higher?*

Yes

Supplied by parents.

Permission given to apply insect repellent containing DEET, once a day when public health authorities recommend its use?*

Yes

Supplied by parents.

Permission given for your child(ren) to have Tylenol/Aspirin, if needed?*

Yes

Supplied by parents. Additional forms required prior to administering medication.

Additional Documents

Please refer to the website to see which documents are required for your application.
These documents may be uploaded now or can be submitted to the office.

Copy of Birth Certificate

Max. file size: 50 MB.

Copy of Shot Record / Immunization Exemption

Max. file size: 50 MB.

Infant Toddler Preschool Child Health

Max. file size: 50 MB.

Vision Screening

Max. file size: 50 MB.

Dental Screening

Max. file size: 50 MB.

Preschool Toilet Training Policy

Max. file size: 50 MB.

Notice Of Nondiscriminatory Policy: Community Lutheran School admits students of any race, color, national and ethnic origin to all the rights, privileges, programs, and activities generally accorded or made available to students at the school. It does not discriminate on the basis of race, color, national and ethnic origin in the administration of its educational policies, admissions policies, scholarship and loan programs, and athletic and other school-administered programs.

Parent/Guardian's declaration upon enrolling a child(ren) in Community Lutheran School:

Putting Christ into education is Christian education. Therefore, it is important that the home, church, and school work together to achieve this goal. Since this is the business of Community Lutheran School, it becomes paramount that all families with children enrolled in the school accept the idea that regular use of God's Word and good worship habits contribute an important part of the program of Christian education.

As a parent interested in Christian education, it is my sincere promise, with the help of God, to adhere to the following commitments:
That my child will attend school regularly, perform all assignments faithfully, and comply with the discipline and policies of Community Lutheran School.
That I will cooperate with the religious training given to my child and sincerely try to be consistent with the teachings of the Christian church.
That I will attend church services regularly and see to it that my child(ren) do also.
That I will actively support any activities that are part of the school program, as well as be active in the Parent/Teacher Organization (PTO).
That I will support the school financially by paying the required fees at the appointed times, donate items when requested by teachers occasionally, and utilize the scrip program when doing my shopping.
To be willing to counsel with a faculty member and/or the Community Board of Christian Education if I become remiss in any of the aforementioned commitments.

Father / Guardian Signature*

Mother / Guardian Signature*

Student Information

Enrolling Parent / Guardian Information

Parent / Guardian Information

Child(ren)'s Medical Information

Child(ren)'s Medical Information

Church Information

Additional Documents

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