ENROLLMENT APPLICATION
(Use web browser FILE, PRINT to print copy of this form)

RIVERCLIFF LUTHERAN SCHOOL
8750 Roswell Road
Dunwoody, GA  30350

NAME OF CHILD  __________________________________________________

Grade Level for 2004-2005 School Year __________________________________

Child’s Birthdate ____________________________________________________

Child’s Social Security #  ______________________________________________

Female ____   Male ____  

Date of Birth ________________________________________________________

Street Address _______________________________________________________

City ___________________ State ________________ Zip Code  ______________

County _________________________ Home Phone #  _______________________

Alternate Phone #    ___________________________________________________

 Child lives with (Circle all that apply):

 Mother            Father            Step-Mother            Step-Father

Grandmother            Grandfather                   Other ____________________________

Please complete for the adults with whom this child lives:

Name ________________________________________________________________

Place and Address of Employment  _________________________________________

Position ______________________________________________________________

Business Phone ________________________________________________________

Cell Phone/ Beeper #  ___________________________________________________

Name ________________________________________________________________

Place and Address of Employment  _________________________________________

Position ______________________________________________________________

Business Phone ________________________________________________________

Cell Phone/ Beeper #  ___________________________________________________

Name ________________________________________________________________

Place and Address of Employment  _________________________________________

Position ______________________________________________________________

Business Phone ________________________________________________________

Cell Phone/ Beeper #  ___________________________________________________

Name ________________________________________________________________

Place and Address of Employment  _________________________________________

Position ______________________________________________________________

Business Phone ________________________________________________________

Cell Phone/ Beeper #  ___________________________________________________

Please list the names and birthdates of this Child’s brothers or sisters.

Name _________________________________ Birthdate _______________________

Name _________________________________ Birthdate _______________________

Name _________________________________ Birthdate _______________________

Name _________________________________ Birthdate _______________________

Name _________________________________ Birthdate _______________________

Name of Church where you are a member: ____________________________________

Has your child been baptized?  Yes_______ No _______

If Yes, where and when? __________________________________________________

Name and Address of person responsible for Tuition and Fees

Name _________________________________________________________________

Address _______________________________________________________________

City, State and Zip Code  __________________________________________________

Phone # ________________________________________________________________

Please explain any special needs of your child (physical, academic, emotional, etc.)

_____________________________________________________________________

_____________________________________________________________________

How can Rivercliff Lutheran School benefit your child and family?

 _____________________________________________________________________

_____________________________________________________________________

Name and address of your child’s previous or current school:

_____________________________________________________________________

_____________________________________________________________________

PLEASE ENCLOSE WITH APPLICATION:

-        $75.00 non-refundable Application Fee payable to Rivercliff Lutheran Church

-        A Copy of child’s Birth Certificate

-        A Copy of immunization records

(NOTE: Not applicable for returning students)

Signature of Parent/ Guardian ____________________________  Date _____________