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St. John's Childcare Application
7877 N Port Washington Rd, Glendale WI 53217
414-352-4150
jessica.koch@stjohnglendale.com
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* Indicates required question
Child's Full Name
*
Your answer
Child's Birthdate
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MM
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DD
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YYYY
Gender
*
Male
Female
Unknown at this time
Required
Requested Start Date
MM
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DD
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YYYY
Address (Street, City, State, Zip)
*
Your answer
Paternal Guardian: Full Name
*
Your answer
Paternal Guardian: Phone Number xxx-xxx-xxxx
*
Your answer
Paternal Guardian: Email
*
Your answer
Paternal Guardian: Workplace & Work Phone
*
Your answer
Maternal Guardian Information Required: Full Name
*
Your answer
Maternal Guardian: Phone Number xxx-xxx-xxxx
*
Your answer
Maternal Guardian: Email
*
Your answer
Maternal Guardian: Workplace and Work Phone
*
Your answer
Emergency Contact Information Required: Full Name
*
Your answer
Emergency Contact: Phone Number xxx-xxx-xxxx
*
Your answer
Emergency Contact: Relationship to Child
Your answer
Authorized Pick Ups: Other than parents, persons who are authorized to pick up the child. Include Full Name. If none, mark NA.
Your answer
Authorized Pick Up: Relationship to Child
Your answer
Authorized Pick Ups 2: Other than parents, persons who are authorized to pick up the child. Include Full Name. If none, leave blank.
Your answer
Authorized Pick Up 2: Relationship to Child
Your answer
How did you hear about St. John's Childcare?
*
Your answer
Religious Affiliation and Place of Worship
Your answer
Would you like more information about St. John's Lutheran Church?
Yes
No
If your child has been baptized, please note their baptismal date.
MM
/
DD
/
YYYY
Child's Doctor and Phone Number xxx-xxx-xxxx
*
Your answer
Describe any allergies or other special physical or emotional needs your child may have: For none put NA
*
Your answer
I give consent for emergency medical care or treatment to be used only if I cannot be reached immediately
*
Yes
No
I give consent for my child to participate in field trips and activities during operating hours
*
Yes
No
I give consent for pictures of my child to be used for (Mark for all approved)
*
Display in the Childcare/Church
On St. John's website
On St. John's Facebook page
Required
If your child has any special medical condition, please mark Yes and complete our Emergency Care Plan
Yes
No
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