Has this student, or any other children in your household, previously been enrolled at First Lutheran? □ Yes □ No

□ Male

□ Female

□ Male

□ Female

□ Male

□ Female

□ Male

□ Female

□ Married □ Divorced □ Separated □ Remarried□ Married □ Divorced □ Separated □ Remarried

□ Widowed □ Single □ Widowed □ Single

Name: Birthdate:

Students Information

Referred to First Lutheran School by a current school family? List their name here:

Student's previous school name, address, and city:

Baptism date:___________________

Race: □Caucasian □African American

□American Indian □Asian

□Hispanic □Non-Hispanic

Enrolling in

Grade:SSN:

Name: Birthdate: Gender Baptism date:___________________

Race: □Caucasian □African American

□American Indian □Asian

□Hispanic □Non-Hispanic

Enrolling in

Grade:

SSN:

Name: Birthdate: Gender Baptism date:___________________

Race: □Caucasian □African American

□American Indian □Asian

□Hispanic □Non-Hispanic

Student Allergies to foods or medicines? Please list here:

Students Live With: o Both Parents o Mother o Father o Guardian Shared custody between parents

Gender Baptism date:___________________

Race: □Caucasian □African American

□American Indian □Asian

□Hispanic □Non-Hispanic

Enrolling in

Grade:

SSN:

Name: Birthdate:

SSN:

Enrolling in

Grade:

Gender

e-mail e-mail

Does employer have a matching gift program □ yes □ no Does employer have a matching gift program □ yes □ no

Employer Name Employer Name

Employer Phone Employer Phone

Home Phone Cell Phone Home Phone Cell Phone

□ Parent or □ Guardian □ Step-parent □ Grandparent

(If parents are separated, please list custodial parent first)

580-762-9950 - FAX 580-762-4243

e-mail: lutheransecretary@yahoo.com www.flcspc.com

Home Address, City, State and Zip Home Address, City, State and Zip (or □ same)

Name Name

Student's previous school name, address, and city:

ENROLLMENT APPLICATION 2016 - 2017

First Lutheran School

1104 N. 4th St., Ponca City, OK 74601

Parent Information

□ Parent □ Guardian □ Step-parent □ Grandparent

Student's previous school name, address, and city:

Student's previous school name, address, and city:

Age Grade

First: Relationship: Phone:

Second: Relationship: Phone:

Phone:

Y or N

Y or N

Participated in a Gifted Program? Y or N

Y or N

Y or N

By signing you agree to the terms stated above.

School Records Requested:______ School Records Received:______

SS Card:______ Birth Certificate:______ Shot Records:______

Experienced difficulties in Math?

Received Honors/Awards?

Currently on Medication?

How did you hear about our school?

Payment Information

Payment Plan: Member One Payment Two Payment 9 months 12 months

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.

Please comment about any of your responses:

Doctor:

Please comment about any of your responses:

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

Signature: Date:

Experienced Discipline Problems? Y or N Ever Suspended?

Family attends Church? □ Yes □ No Where?

Had Learning Difficulties in Reading?

Y or N

Y or N

Why are you considering our school?

Has student repeated a grade? Y or N Received Tutoring?

Educational Background

Part of a Special Learning Program?

Family Information

Contact Information

Person(s) to contact in emergency if parents cannot be reached:

Purpose of Enrollment

Please answer the following questions. Circle Yor N.

Y or N

Brother (s) & Sister (s) names (other than listed above) School Attending