GSLC Application & Registration Form 2025

Child's Information

Child's Full Name *

Gender *

Birthday *

Child Age (As of August 1st, 2025) *

Phone number *

Address *

Name your child prefers to be called (name we will teach your child to spell) *

Family Information

If a guardian other than a parent is entering information, please state the relationship to the child.

Mother's Information

Mother's Name *

Address

Mother's Employer *

Mother's Employer Phone Number *

Mother's Work Hours *

Father's Information

Father's Name *

Address

Father's Employer *

Father's Employer Phone Number *

Father's Work Hours *

Family Information

When speaking with the child, we would like to be sensitive to their specific circumstances. Please let us know with whom the child lives on a regular basis and also if a parent is deceased. *

(ex: one home-both parents, two homes-parents/step-parents, one home guardians/grandparents, etc)

Names of Siblings & Age *

Pick-Up Authorization and Emergency Contacts

Persons authorized to pick up the child - other than the parent (will call in the order listed)

Pick-Up #1

Pick-Up #1: Name *

Pick-Up #1: Relationship to Child *

Phone number *

Pick-Up #1: Call in the event of an emergency *

Yes

No

Pick-Up #2

Pick-Up #2: Name

Pick-Up #2: Relationship to Child

Phone number

Pick-Up #2: Call in the event of an emergency

Yes

No

Pick-Up #3

Pick-Up #3: Name

Pick-Up #3: Relationship to Child

Phone number

Pick-Up #3: Call in the event of emergency

Yes

No

Pick-Up #4

Pick-Up #4: Name

Pick-Up #4: Relationship to Child

Phone number

Pick-Up #4: Call in the event of emergency

Yes

No

Pick-Up #5

Pick-Up #5: Name

Pick-Up #5: Relationship to Child

Phone number

Pick-Up #5: Call in the event of emergency

Yes

No

Policy

(Under no circumstances will a child be released to anyone not known to the school without authorization from a parent or guardian)

Health/Development

Allergies *

Allergies: Type of Treatment

Health: Nose Bleeds

Yes

No

Health: Presently taking medicine? (Explain) *

Health: Does your child have any other illness or special needs we should be aware of? *

Health: Is your child under the care of a doctor for any of these? (If yes, explain) *

Developmental: Does your child have temper tantrums? *

Yes

No

Developmental: Does your child have a speech problem? *

Yes

No

Developmental: Unusual fears/problems

Developmental: Is your child right or left handed? *

Right

Left

Both

Developmental: Do you have any concerns about your child's development or ability to learn? (If yes, explain) *

Experiences

Experiences: What are your child's favorite activities? *

Experiences: Church affiliation *

Experiences: Church attendance *

Regular

Seldom

Never

How did you find out about Good Shepherd Learning Center? *

Church Sign

Bench Ad

Facebook

Phone Book

Friends

Other

If Friends or Other, please Specify

Call Service Information

Good Shepherd Learning Center has a call service through Brady Lane Church that will notify you of any important messages, school closings or delays. A call will be sent before the start of preschool classes to the telephone number(s) you provide if inclement weather causes a closing or delay. Please list only the numbers you would like to receive this call as the service will call ALL numbers entered.

Contact #1

Call Contact #1: Name *

Call Contact #1: Relationship to Child *

Phone number *

Contact #2

Call Contact #2: Name

Call Contact #2: Relationship to Child

Phone number

Contact #3

Call Contact #3: Name

Call Contact #3: Relationship to Child

Phone number

Contact #4

Call Contact #4: Name

Call Contact #4: Relationship to Child

Phone number

Parental Agreement

Emergency Medical Care

In case of sickness or accident, I hereby consent that the Good Shepherd Learning Center provide first aid treatment and/or emergency care through a hospital or doctor.

Medical: Name of Physician *

Medical: Emergency Hospital preference *

Medical: I authorize Good Shepherd Learning Center to administer Neosporin for minor cuts/scrapes.

Yes

No

Discipline

I hereby understand and give my consent that the Good Shepherd Learning Center will enforce its standards of discipline and obedience on my child. I understand that the school has full discretion in the discipline of my child through use of time outs and a reward system. (NOTE: Corporeal punishment is not practiced at Good Shepherd Learning Center.)

Religious Instruction

Throughout the course of the year, our teachers will provide basic Christian instruction dealing with prayer, the birth and resurrection of Jesus, the fact that God loves them, etc. I understand and give my consent to the Good Shepherd Learning Center to teach my child in this manner.

Photography Release

I grant Good Shepherd Learning Center and Brady Lane Church permission to take photographs of my child and use them in the area(s) checked below in print and/or electronically. I understand that photographs of my child will be included in the preschool newsletter that goes home monthly, only to preschool families.

Permissions *

I understand and consent to all the above information for Good Shepherd Learning Center on medical care, discipline, religious instruction, and photography in regards to my child. I agree to read and comply with the policies and procedures stated in the Good Shepherd Learning Center Handbook including discipline and religious instruction regarding my child in the classroom.

Permission to use photographs (please check all that apply)

Website

Facebook

Advertising/Publicity

Child's Name *

Parent/Guardian Electronic Signature (Print Name) *