6th Grade 5:40-6:25 pm (Room 102-103) Wednesday Education Registration

Student Name Student Name * First Last
Student Gender *

Student Gender Male Female
Student Birthdate Student Birthdate * / MM / DD YYYY
Student Cell Phone Student Cell Phone - ### - ### ####
I can help:

I can help: Teach (6-Week Session) Classroom Mentor (24-Weeks) Help with Special Events
Parents will be assigned to teach 6 weeks during the school year. Please check the month(s) that work best for you:

Parents will be assigned to teach 6 weeks during the school year. Please check the month(s) that work best for you: September October November December January February March
Parent (Caregiver) Name #1 Parent (Caregiver) Name #1 * First Last
Parent (Caregiver) Cell Phone #1 Parent (Caregiver) Cell Phone #1 * - ### - ### ####
Parent (Caregiver) Email #1 *
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Parent (Caregiver) Name #2 Parent (Caregiver) Name #2 First Last
Parent (Caregiver) Cell Phone #2 Parent (Caregiver) Cell Phone #2 - ### - ### ####
Parent (Caregiver) Email #2
My student(s) would like to be in class with?
Do your children have any special needs or restrictions?
Are you a member of Calvary Lutheran?

Are you a member of Calvary Lutheran? Yes No Would like to...
My child has permission to participate in any activity, games, hiking, and field trips planned for the Calvary Lutheran Education Program. I agree that the church, its personnel and volunteers and teachers will not be held responsible and hereby release them from any accidents which may occur.
THIS IS A RELEASE. I HAVE READ AND UNDERSTAND THIS RELEASE. *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date * / MM / DD YYYY
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