Infant/Toddler Summer Enrollment Form
Immanuel Lutheran School is currently enrolling infants and toddlers for the summer.  Our Summer days are June 1-August 17th. This is only enrollment for the summer, not our 2021/2022 school year.  Please email our Director, Jillian Van Leer, with any questions at jillian.vanleer@imlutheran.org.  Blessings on your day!  We look forward to working with you and your child!
****Birthdate of August 1, 2018 - July 31, 2019*********



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Child's Name *
Child's Date of Birth/Due Date *
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Child's Address *
Is your child Baptized?
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If child is Baptized, what is the date of their Baptism?
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Allergies or health concerns *
Guardian #1 (Relation to child) *
Guardian #1 Name: *
Guardian #1 Address (if different from child)
Guardian #1 Phone Number *
Guardian #1 email address *
Guardian #2 (Relation to child)
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Guardian # 2 Name
Guardian #2 Address (if different from child)
Guardian #2 Phone Number
Guardian #2 email address
Child's Pediatrician name and phone number *
Emergency Contact #1 (Please include name, relation to child, and phone number) *
Emergency Contact #2 (Please include name, relation to child, and phone number) *
Are Emergency Contacts allowed to pick up child? *
Which days will you need childcare (choose one)? Limited space available. *
Required
The following person(s) have my permission to pick up my child (please include name, relation to child and phone number)  Person 1 *
The following person(s) have my permission to pick up my child (please include name, relation to child and phone number)  Person 2
The following person(s) have my permission to pick up my child (please include name, relation to child and phone number)  Person 3
The following person(s) have my permission to pick up my child (please include name, relation to child and phone number)  Person 4
Family Church Membership *
Do you currently have a child attending Immanuel Lutheran School? *
I agree to pay $50 per day that my child is in the program for the summer session.
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How did you hear about Immanuel Lutheran's Infant and Toddler program?
I agree to pay a $50 Summer Enrollment fee.  Payment of Enrollment fee will guarantee your child's spot in the program.  Our Infant/Toddler Director will contact you upon completion of your enrollment form.  Payment will be due within 14 days of contact. Enrollment fee is non-refundable. *
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