Luther’s Little Lambs Registration Form

Please complete the following form to enroll your child in Emmanuel Lutheran’s Luther’s Little Lambs program

Student's Name (Required Field) *

Street Address (Required Field) *

City/State/Zip (Required Field) *

Student's Date of Birth (Required Field) *

Child's Age

Parent/Guardian Name (Required Field) *

Relationship (Required Field) *

Parent/Guardian's Cell Phone Number (Required Field) *

Parent/Guardian's Email Address (Required Field) *

Parent/Guardian's Street Address (if different from student)

Parent/Guardian's City/State/Zip (if different from student)

Would you like to enter another Parent/Guardian *

Known Allergies/Special Needs:

Medications:

Emergency Contact Name (Required Field) *

Emergency Contact Relationship (Required Field) *

Emergency Contact Phone Number (Required Field) *

Emmanuel Lutheran Church Photo Release: (Required Field) *

Grants permission to Emmanuel Lutheran Church to use images of the youth named on this form on the Emmanuel Website and Facebook page

Parent/Guardian's Name Who is Giving Photo Permission (Typing in your name will serve as your signature) (Required Field) *

Parent/Guardian's Email (Required Field) *

Date Signed (Required Field) *

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