ELC Registration Form 2021-2022

Thank you for choosing St. John ELC! All registration must be made using this online form. Payment of the $150 Non-Refundable Registration Fee must be received before this application will be processed and enrollment finalized. You may pay the fee by mailing or dropping off a check to St. John Lutheran Early Learning Center, 7214 South Cass Avenue, Darien, IL 60561 or using the school's online payment portal.

Online Payment of Registration Fee:
sjlcdarien.org
Child's Name * First Last
Gender * Male Female
Child's Birth Date * / MM / DD YYYY
Child's Baptism Date / MM / DD YYYY
Child's Primary Home Mailing Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Preferred Primary Contact Name & Phone Number If Child Becomes Ill During the School Day First Last
- (###) - ### ####
For what class are your registering the child? * Two's Class: T/TH Three's Class: M/W/F Three's Class: M/T/W/TH/F Four's Class: M/W/F Four's Class: M/T/W/TH/F
Are you interested in enrolling the child in before and/or after school extended care with enrichment? * No Yes, Only Before School (Available to Threes and Fours from 7:30 a.m. to 8:45 a.m.) Yes, Only After School (Available from 11:45 a.m. to 5:00 p.m. only to 5-Day a Week Threes and Fours until COVID-19 mitigations are lifted) Yes, Both Before & After School (Available as outlined above)
Are there any allergies or health concerns for your child? Please explain.
If there are none, please indicate that by writing "None." *
Child's Mother's Name * First Last
Mother's Primary Home Mailing Address (if different from child's)
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Mother's Primary Email Address *
Mother's Primary Phone Number * - (###) - ### ####
What is the Mother's Occupation? *
Mother's Hours of Employment: Start Time * : HH MM AM/PM
Mother's Hours of Employment: End Time * : HH MM AM/PM
Mother's Work Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Mother's Work Phone Number * - (###) - ### ####
Child's Father's Name * First Last
Father's Primary Home Mailing Address (if different from child's)
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Father's Primary Email Adress *
Father's Primary Phone Number * - (###) - ### ####
What is the Father's Occupation? *
Father's Hours of Employment: Start Time * : HH MM AM/PM
Father's Hours of Employment: End Time * : HH MM AM/PM
Father's Work Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Father's Work Phone Number * - (###) - ### ####
What is the relationship between the parents? * Married Divorced Other
Emergency Contact Person's Name * First Last
Emergency Contact's Primary Phone Number * - (###) - ### ####
What is the Emergency Contact's relationship with the Child? * Family Friend Aunt or Uncle Grandparent Step-Parent Neighbor Other
Child's Doctor's Name * First Last
Doctor's Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Doctor's Primary Phone Number * - (###) - ### ####
What is your family's home church?
Do you agree to pay the one-time, non-refundable registration fee? * Yes
How did you hear about St. John Early Learning Center? (Check all that apply.) * Home Church Is St. John Sibling Attended Parent Attended Website Sign on Church Property Online News Posting Print Ad Flyer or Poster Brochure Door Hanger Lawn Sign Church Event Referred by the following person:
Name First Last
Other
Other:
Type the letters you see in the image below.

ELC Registration Form 2021-2022

ELC Registration Form 2021-2022

Online Payment of Registration Fee: sjlcdarien.org

Online Payment of Registration Fee:
sjlcdarien.org