Join us July 19th through July 24th
Right here at St. John's Lutheran Church
703 Third Avenue
Sterling, IL 61081

Student Name:

Parent/Guardian Name:

Address:

Parent/Guardian Address (If Different from Student):

City:

State:
IL IA WI MO IN

Zip code:

Home Telephone:

Cell Phone:

Work Phone:

Home E-Mail Address:


Home Congregation (Name & City/State):

From time to time St. John's sends out information regarding special events and other community items. Would you like to receive these notices? Note: St. John's uses e-mail address internally only.
      YES
      NO

Child Birth Date:


Grade last completed:
Pre-K K 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade High School

Baptism Date:

Age:
3 4 5 6 7 8 9 10. 11 12 13 14 15 16 17 18

In case of an emergency (when the parent/guardian cannot be reached) please contact:
Name:                                                     Telephone: 
Relationship to Child:

Please list any allergies (including food allergies) the staff should be aware of:

Please list any special accommodations the staff needs to be conscious of:

Personal Responsible for picking up this child:
Name:
Telephone:

Please list siblings (age, first and last name if different from student):

Check this box to digitally sign your registration form, then type your name in the space below.

Thank you for registering your child(ren)!