Trinity Lutheran Church

820 Lockett Road      Kirkwood, Missouri

Welcome to the 2012-2013 school year of Trinity's Parent's Day Out program. To register your child, please fill out the form below and press "Submit form", one form for each child, please.   (* = required)

*Child's name:      *Birth date:   
*Address line 1:
Address line 2:    *City:    *State:    *ZIP:
*Registering for: (check all that apply)
    Mondays     Tuesdays     Wednesdays     Thursdays     Fridays
_______________________________________________________________________________________
*Father's Name: 
   *Phone number: (Home)    (Cell)
*Mother's Name:
   *Phone number: (Home)    (Cell)
*Status:    Married       Single       Divorced
Church affiliation:
Baptized: Yes      No
*Emergency contacts:
   *Name: *Phone:
   *Name: *Phone:
_______________________________________________________________________________________
Comments:
I understand that in an emergency I will be contacted immediately. I will take appropiate action for my child. I will accept financial responsibility for the charges associated with this action. If I cannot be reached to make necessary arrangements or in a critical emergency requiring immendiate care, I hereby authorize Trinity Lutheran staff to call 911 and administer first aid. I hereby authorize Trinity Lutheran to contact the doctor/hospital listed below:
*Doctor's name and telephone: 
*Hospital name and telephone:  
*I/we understand and accept the above conditions (name of person submitting):
     
*E-mail: _______________________________________________________________________________________
$65.00 registration fee must be mailed to reserve a spot.
Mail to: Trinity Lutheran Church - PDO
            820 Lockett Road
            Kirkwood MO 63122