PEACELUTHERANSCHOOL School Year _______-_______
11701 E. 12 Mile Road Student will be entering Grade_____
Warren, Michigan 48093 Registration Fee (K-8): __________
(586) 751-8011 Family Referred ________________
Number of Vouchers Issued ______
*ENROLLMENT APPLICATION
Please print and complete in full: Please see back of form for important details
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CHILD’S NAME:
(Last, First, Middle)
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DATE OF
BIRTH:
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BIRTHPLACE:
(City & State)
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BAPTIZED?
____Yes ____ No
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DATE OF
BAPTISM:
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PARENT/GUARDIAN’S ADDRESS, CITY, ZIP CODE:
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HOME PHONE:
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FATHER’S EMAIL ADDRESS:
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MOTHER’S EMAIL ADDRESS:
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FATHER’S NAME:
ADDRESS/PHONE (IF DIFFERENT):
CELL PHONE:
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MOTHER’S NAME:
ADDRESS/PHONE (IF DIFFERENT):
CELL PHONE:
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**APPROX YEARLY INCOME (Please provide)
FatherRANGE (NUMBER #): _________
MotherRANGE (NUMBER #): ________
“OR” TOTAL RANGE (NUMBER #): ________
*See back of this form for IncomeRange #’s Key
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(Income Information is Strictly Confidential)
Please see back of form for details
This information provided is used for government funding/grants.
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NATIVE COUNTRY:
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NATIVE COUNTRY:
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BROTHERS/SISTERS (Give names and birth dates):
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CHURCH AFFILIATION (Denomination & Congregation):
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ADDRESS:
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PHONE:
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PASTOR’S NAME:
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SCHOOL PREVIOUSLY ATTENDED (Name, Address, Phone#):
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SCHOOL DISTRICT IN WHICH YOU LIVE (please provide):
(Bus available for Warren Woods District families only)
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EMERGENCY INFORMATION (Allergies or Medical Conditions):
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DOCTOR’S NAME:
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DOCTOR’S PHONE:
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EMERGENCY CONTACT PERSON:
(Name & Phone)
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FATHER’S WORK PHONE:
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MOTHER’S WORK PHONE:
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All the above information is accurate to the best of my knowledge and I understand that all registration monies are non-refundable unless Board of Education and/or School Principal deny enrollment.
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PARENT
SIGNATURE:
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PARENT
SIGNATURE:
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DATE:
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DATE:
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Please read and sign the “Parental Agreement” on the back of this form.
PARENTAL AGREEMENT
We, as parents who are accepting the challenge to “Train up a child in the way he should go”, do state that this training will be carried on in the home. We shall place our trust in the Christian school to extend that training more completely.
We pledge that the family will show its sincere Christian purpose by attending church services regularly.
We hereby invest authority in the school to discipline our child as necessary. We further agree that we will cooperate and discipline our child in the home as needed.
We pledge that, if for any reason, our child is not benefiting from the school program and it is suggested that enrollment be found elsewhere, we will withdraw him/her quietly and without delay.
We authorize emergency medical care in the event of serious illness or accident, if parents cannot be reached.
We agree to pay for any school property damage or loss by our child(ren). This shall include but is not limited to damage or loss to buses, grounds, building fixtures, furniture, equipment, books, and supplies.
We further understand that a registration fee is due at the time of registration and is not refundable unless the pupil is not accepted.
We the undersigned hereby accept the responsibilities for all expenses incurred in the education of the child(ren) listed herein and agree to pay these expenses on the date which they are due. We understand that when delinquencies in payment arise, services may be terminated. We understand that report cards will be withheld at the end of the school year and records will not be transferred if required payments are not made in full.
We as parents of the student applicant do sincerely give our pledge to all items as stated above.
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Parent(s) or Legal Guardian
*PeaceLutheranSchool distributes a school roster to all enrolled families and staff, which contains names, addresses, phone numbers and cell phone numbers. If there is any information that you wish not to be included on this roster, please indicate with the word “private”.
**Please be assured that the requested income levels provided are kept strictly confidential. This provided information is compiled with other school families living in your school district to determine eligibility of grants and funding available through the public school systems for special resources, and are not used adjacent with your personal information, without your written permission to do so.
Annual Income Level IncomeRange Number
$20,000 or Below 1
$21,000-$40,000 2
$41,000- $60,000 3
$61,000- $80,000 4
$81,000-$100,000 5
$101,000-$120,000 6
$121,000-$140,000 7
$141,000-$160,000 8
$161,000-$180,000 9
$181,000-$200,000 10
$201,000-$220,000 11
$221,000-$240,000 12
$241,000-$260,000 13
$261,000-$280,000 14
$281,000 or above 15