Registration for                                                                         3 yr old or 4 yr old
Little Lambs Preschool                                                                   (Circle one)
Good Shepherd Lutheran Church
1436 21st Ave North, Fort Dodge IA 50501
Phone (515) 573-3174

Date ____________

Child's name _____________________________________________________
                                     First                          middle                         Last

Address _________________________________________________________

Do you use a nickname? (ex. Nick-Nicholas, Jake-Jacob) __________________

Gender _______________ Birthday ____________ Age by Sept. ___________

Church Affiliation (Name) ____________________________________________

Is your child baptized? _________ If no, would you like information? __________

Parent's Marital Status: Married _____ Separated _____ Divorced __________

                                         Single ________ Deceased ______

Mother's Name _______________________________ Ph. # _______________

Place of employment __________________________ Ph. # _______________

Father's name ________________________________ Ph. # _______________

Place of employment __________________________ Ph. # _______________

Step-Father's name ____________________________ Ph. # _______________
                                    (or other male role model in the household)

Place of employment __________________________ Ph. # _______________

Other children in the home? (Please state name and age) __________________

________________________________________________________________

Has your child attended school before? ________________________________

Any allergies or handicaps we need to be aware of? ______________________

________________________________________________________________

Does he/she get along with others? ___________________________________

________________________________________________________________

Give any further information which you believe will be helpful to us in
understanding your child. ____________________________________________

________________________________________________________________

During the year there are times when we would hand out class list names for
certain days, such as Valentine's and outside activities such as birthday parties.
To do so we need your permission. Please sign below if you want your child on
the class list.
Parent signature __________________________________________________

Please return or send this form to the church office along with the required
deposit. This deposit is non-refundable.

3 yr olds - $70.00 ($20 registration fee plus $50 for the last month's tuition)

4 yr olds - $90.00 ($20 reg. fee plus $70 for the last month's tuition)

Little Lambs Preschool admits students of any race, color, and nationality, and ethnic origin to all
the rights, privileges, programs, and activities generally accorded or made available to students at
school. It does not discriminate on the basis of the afore stated in administration policies and other
school administered programs.

How did you learn about our Preschool? (check one)

___ Newspaper ___ Channel 12 ___ Church ____ Friend or relative ___ Radio

___ Phone book ____Internet ____ Other (explain) _____________________

Please initial that you have received the following forms:

_____Registration Form
_____Emergency Medical treatment Authorization
_____Pick-up Permission Form
_____Travel and Activity/Picture release
_____Library form
_____DHS Criminal History Record Check
_____Little Lambs Preschool Handbook
_____Physical Examination form