Visit/Join/Register

Referral Information

Were you referred by another family? What is their name?

Student Information

Student #1

* Student #1 First Name

* Student #1 Last Name

* Your Child's prefered name?:

* What pronouns does your child use?

* Date of Birth

* Home Address for Student(s)

* City, State & Zip

Email Address for Student

Cell phone for Student

* Grade in school

Comments

If you checked any allergies, please give us details: Epi-pen information; if the allergy is inhaled, ingested or from contact; specific medication allergy. This information is extremely important in the event of an emergency.

Epi-Pen

NoYes

If yes, does your child carry the epi-pen or would you like us to keep it in the office or with the teacher?

What medications does your child take regularly?

Please be specific as this could be important in the event of an emergency.

What medications does your child carry with them?

Some examples would be: Epi-pen, insulin, inhaler, benedryl, etc.

Is there anything else we should know about your child?

Does your child have any learning needs such as an IEP?

Student #2

Student #2 First Name

Student #2 Last Name

Student #2: Your Child's prefered name?:

Student #2: What pronouns does your child use?

Student #2 Date of Birth

Home Address for Student(s)

City, State & Zip

Email Address for Student #2

Cell phone for Student #2

Student #2 Grade in School

Student #2 Comments

Student #2 Epi-Pen

NoYes

Student #2 If yes, does your child carry the epi-pen or would you like us to keep it in the office or with the teacher?

Student #2 What medications does your child carry with them?

Some examples would be: Epi-pen, insulin, inhaler, benedryl, etc.

Student #2 What medications does your child take regularly?

Please be specific as this could be important in the event of an emergency.

Student #2 Is there anything else we should know about your child?

Does your child have any learning needs such as an IEP?

Student #3

Student #3 First Name

Student #3 Last name

Student #3 Your Child's prefered name?:

Student #3 What pronouns does your child use?

Student #3 Date of Birth

Home Address for Student(s)

City, State & Zip

Email Address for Student #3

Cell phone for Student #3

Student #3 Grade in School

Student #3 Comments

Student #3 Epi-Pen

NoYes

Student #3 If yes, does your child carry the epi-pen or would you like us to keep it in the office or with the teacher?

Student #3 What medications does your child take regularly?

Please be specific as this could be important in the event of an emergency.

Student #3 What medications does your child carry with them?

Some examples would be: Epi-pen, insulin, inhaler, benedryl, etc.

Student #3 Is there anything else we should know about your child?

Does your child have any learning needs such as an IEP?

Family Information

Parent/Guardian #1 will receive all school communications and invoices. Please indicate below if Parent/Guardian 2, 3 or 4 would like to receive these as well.

* Parent/Guardian #1 First Name

* Parent/Guardian #1 Last Name

* Relationship to Student(s)

* Address (write "same" if same as student)

City, State & Zip

* Email address

* Cell Phone

Work Phone

Parent/Guardian #2 First Name

Parent/Guardian #2 Last Name

Relationship to student(s)

Would parent/guardian 2 like to receive invoices and information?

YesNo

Address (if different from Student)

City, State & Zip

Emergency Contact?

YesNo

Email address

Cell Phone

Work Phone

Parent/Guardian #3 First Name

Parent/Guardian #3 Last Name

Relationship to students(s)

Would parent/guardian 3 like to receive invoices and information?

YesNo

Address (if different from student)

City, State & Zip

Emergency Contact

YesNo

Email address

Cell Phone

Work Phone

Parent/Guardian #4 First Name

Parent/Guardian #4 Last Name

Relationship to student(s)

Would parent/guardian 4 like to receive invoices and information?

YesNo

Address (if different from Student)

City, State & Zip

Emergency Contact

YesNo

Email address

Cell Phone

Work Phone

* Who may pick up your student(s)? Please give full names and cell numbers.

EMERGENCY CONTACTS: We will need THREE total emergency contacts: you and two others. If three are not listed among family members above, please provide more in the space below. Please list their names and contact phone numbers.

Medical Release

I/We give permission for my/our child(ren) to receive basic first aid while at SJC. I/we have informed Shalom Sunday School/SJC staff of my child's medical conditions. I/we consent to emergency medical treatment by a licensed emergency medical team (including transport by aid car or ambulance) when deemed immediately necessary while at SJC, and I/we cannot be contacted.

Agree?

YesNo

Miscellaneous

Field Trip Authorization

I/We give permission for my/our child(ren) to attend SJC field trips, and understand that transport may be provided by parents, public transit, or walking. Parents will be notified of field trips in advance.

Photography/Video Opt-out

Photography/Video Opt-outI/We do NOT allow SJC to use photographs or video of my CHILD(REN) on the SJC website and in publicity materials.

Signature

I attest that the information I have stated above is true and accurate to the best of my knowledge.

* Electronic Signature

Type your first and last name to confirm the truth and accuracy of this document.

* I understand that checking this box constitutes a legal signature

I understand that checking this box constitutes a legal signature

Would You Like to Visit Our School?

Enrollment