Profile Form-Spl Cncrns-New STDNT-LTR Size

Lincoln Lutheran Student Profile Form - New Student
Please complete all sections of this form. The information is a vital part of our student records.
Please print legibly, except for items requesting signature.
Student Information
Student’s Legal Name:
Mailing Address:
Date of Birth:
Gender:
Ethnicity:
Physical Address:
Home Phone :
Student Cell:
Parent/Guardian Information
Mother’s Name:
Employer:
Work Phone / Cell Phone:
Email Address:
Father’s Name:
Employer:
Email Address:
Stepparent / Guardian Name:
Employer:
Email Address:
Student Resides With:
Custodial Parent / Guardian:
Emergency Contact Info.
In an EMERGENCY situation if we cannot reach you at home or work, please list two people who have agreed to take
responsibility for your child and consented to the release of their phone numbers so we may reach them as an alternative.
Name / Phone # of Contact #1:
Relationship to Student:
Name / Phone # of Contact #2:
Relationship to Student:
Medical Information
Doctor’s Name / Group Name:
Doctor’s Phone Number:
Doctor’s Address:
Dentist’s Name / Group Name:
Dentist’s Phone Number:
Dentist’s Address:
If deemed necessary, ______________________________ will be sent to your family doctor or an emergency room at
parent/guardian’s expense. As a parent/guardian, I authorize medical personnel to render necessary medical treatment to
my child. I give consent to release this information to Lincoln Lutheran personnel to promote the health and safety of my
child, thus enhancing his/her ability to learn.
Signature Required: ___________________________________________________________ Date: _________________
The above signature acknowledges I have read and consent to the above.
Lincoln Lutheran School Student Profile Form - New Student (cont.)
Insurance Information
Insurance Company:
Policyholder Name:
Policy #:
Member ID:
All students must have the above insurance information on file. Lincoln Lutheran does not provide insurance for students,
but families may purchase accident insurance through the school. Forms are available through the school office.
Health History
List known allergies. Provide dates if
hospitalized with allergies:
List diseases, operations, injuries & year:
List Medications administered at home:

Medications to be administered at school:
Note: A Medication Form MUST BE COMPLETED and placed on file in School Office to allow school to
administer medication of any sort. This includes Tylenol or other pain relievers, antacids, etc.
No Child Left Behind – For Grades 9 – 12 Only

No Child Left Behind of 2001 states that schools must comply with a request by a military recruiter or an
institute of higher education for secondary students’ names, addresses and phone numbers unless the parent
denies this request in writing. Non-compliance by the school will result in loss of federal funds.
I grant permission to release information concerning this student to a military recruiter or an institute of higher
education. Yes / No Please initial: _______
Information for Non-Custodial or Additional School Mailing

Name:
Address:
Email:
School / Church Information
Last School Attended:
Grades
School District in which Student Resides:
Church Membership:
Parent / Guardian Signature: ____________________________________
Date: ____________ For Office Use Only

PowerSchool Entry ____
Family Rep: Y / N
Date: _______________
Lincoln Lutheran
Special Concerns Survey
The information from this form will allow Lincoln Lutheran to make decisions on how to best serve you and
your child. Having a special concern will not in and of itself disqualify your student from attending Lincoln
Lutheran. Please complete this form as thoroughly and accurately as possible.
Applying
Student’s Name ___________________________________________ for Grade ___________
Previous School ________________________________________________________________
Name of a Teacher Who Knows You Well ___________________________________________
1. Has your student had any previous problems with attendance (extended absences, tardiness, truancy, chronic
illness)? No ___ Yes ___ If yes, please explain: _____________________________________
______________________________________________________________________________
2. Has your student received any detentions, suspensions, or expulsions? No ___ Yes ___
If yes, please explain _____________________________________________________________
3. Has your student ever been asked to withdraw from a school? No ___ Yes ___
If yes, please explain _____________________________________________________________
4. Has your student undergone counseling (pastoral or professional) for any reason?
No ___ Yes ___ If yes, please explain the circumstances: _____________________________
______________________________________________________________________________
5. Has your student skipped a grade? No ___ Yes ___ If yes, which grade? ______
6. Has your student repeated a grade? No ___ Yes ___ If yes, which grade? ______
7. Has your student ever been referred for special education testing? No ___ Yes ___
8. Has your student had any history of drug or alcohol abuse? No____ Yes____ (HIGH SCHOOL ONLY 8 & 9)
If yes, please explain____________________________________________________________
9. Has your student had any involvement with the justice system (juvenile or criminal) ? No____ Yes _____
If yes, please explain:___________________________________________________________________
10. Does your student currently have or has your student had an IEP (Individual Education Plan)
No ___ Yes ___ If yes, what year was the plan written? ______________________________
Date of anticipated retesting ______________________________________________________
11. Does your student currently have or has your student had a 504 Plan? No ___ Yes ___
If yes, what year was the plan written? ___________
12. Does your student have a health condition that may affect their ability to learn? Examples would include,
but are not limited to: attention deficit disorder, hearing or vision impairments, mood disorders.
No ___ Yes ___ If yes, please explain: ____________________________________________
______________________________________________________________________________
13. Does your student have a health condition that will require accommodations in the classroom? Examples
would include, but are not limited to: diabetes, seizure disorders, gastrointestinal disorders, orthopedic
issues. No ___ Yes ___ If yes, please explain: __________________________________________
______________________________________________________________________________
14. Are there any other factors in your student’s life about which we should know to help us provide the best
possible education? No ___ Yes ___ If yes, please explain: ___________________________
______________________________________________________________________________
Failure to provide truthful information during the admissions process or failure to disclose factors that may
impact your student’s education at Lincoln Lutheran are sufficient grounds to deny admission or may subject
your student to expulsion per school policy.
Parent/Guardian Name (Please Print Legibly): ___________________________________________
Parent/Guardian Signature: _______________________________________ Date: ____________

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Lincoln Lutheran Student Profile Form - New Student

List Medications administered at home:

No Child Left Behind – For Grades 9 – 12 Only

Information for Non-Custodial or Additional School Mailing

Parent / Guardian Signature: ____________________________________

Date: ____________ For Office Use Only

Previous School ________________________________________________________________

Name of a Teacher Who Knows You Well ___________________________________________

If yes, please explain____________________________________________________________

Parent/Guardian Name (Please Print Legibly): ___________________________________________

Parent/Guardian Signature: ___________________________ Date:

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