6th Grade 5:30-6:15 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?
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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