First Lutheran Church of Placerville - Pre School registration

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Homepage: Leave this field homepage blank:
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Child name*:

Birth Date*:

Begin Date*:

Number of days*:

5432drop in only

Father's name*:

Address*:

City, State and zip*:

Phone *:

Place of busines*:

Work Phone*:

Mother's name*:

Address*:

City, State and zip*:

Phone *:

mother's place of business*:

Work Phone*:

Father's home church:

Mother's home church:

Doctor's name:

Doctor's phone*:

Dentist's name*:

Dentist's phone*:

Whom to call in emergency*:

Emergency call 2*:

Emergency call 3:

Is child baptized?*:

YesNo

Date baptized:

Does your child attend church?*:

Do you give your permission for your child to be photographed at school?*:

If yes, do you give your permission for child's photo to be posted on web site?*:

Verification:

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