Child's Name (First & Last):
Date of Birth (mm/dd/year):
Grade Entering Fall 2017:
Potty Trained: At this time we are unable to accept children that are not potty trained and in diaper, unless they are needed for medical use.
City, State, Zip:
Home Telephone with area code:
Parent/Caregiver Cell Phone:
Home E-mail Address:
In Case of Emergency, Contact (Name/Number):
Relationship to Child:
Allergies or Other Medical Conditions:
Registered with the school for St. Mark's Before/After care during V.B.S. week?
Friend Request: Your child may request 1 friend in their class of the same grade. Friend requests can only be accepted until June 1st. We will do our best but cannot guarantee friend requests after this date.
© 2013 - St. Mark’s Lutheran MinistriesMember of the Lutheran Church - Missouri Synod