Preschool Enrichment Enrollment - Fall 2026 "*" indicates required fields NameThis field is for validation purposes and should be left unchanged.Student InformationChild's Name* First Last Nickname (optional) Child's Date of Birth* MM slash DD slash YYYY Is this child listed above currently enrolled in Immanuel's Early Childhood program?* Yes No Gender* Male Female Child's Current Teacher*Mrs. RatliffMrs. CampbellMrs. WoellMrs. TresClass SelectionPlease select the dates for which you would like to register. You may complete the form again any time you would like to add additional dates. We are not able to offer refunds for unused days. Each class requires a minimum of four students to run and can accept a maximum of ten students. After selecting dates and completing the form, you will be redirected to PayPal to complete payment.Monday Enrichment/Stay & Play - $25 per day September 14 September 21 September 28 October 5 October 19 October 26 No Enrichment/Stay & Play October 12Monday Enrichment/Stay & Play Total$25 per dayWednesday Lunch Bunch - $11 per day September 16 September 23 September 30 October 7 October 14 October 28 No Lunch Bunch October 21Wednesday Lunch Bunch Total$11 per dayWednesday Enrichment/Stay & Play - $25 per day September 16 September 23 September 30 October 7 October 14 October 28 No Enrichment/Stay & Play October 21Wednesday Enrichment/Stay & Play Total$25 per sessionFriday Enrichment/Stay & Play - $25 per day September 18 September 25 October 2 October 9 October 23 October 30 No Stay & Play October 16Friday Enrichment/Stay & Play Total$25 per sessionTotal Amount Due Price: $0.00 Parent/Guardian InformationName* First Last My Relationship to this Child is*Mother, Father, Legal Guardian, Aunt, Uncle, Grandparent, Etc.Email* Secondary Email (optional) Primary Phone Number*Okay to text PRIMARY PHONE if needed?* Yes No Secondary Phone NumberIn case of emergencyOkay to text SECONDARY PHONE if needed? Yes No Address* Street Address Address Line 2 City State ZIP / Postal Code Add another parent/guardian?* Yes No Additional Emergency ContactPlease indicate a second person we can contact in case of emergency if we are unable to reach the parent/guardian listed above.Name* First Last My Relationship to this Child is*Mother, Father, Legal Guardian, Aunt, Uncle, Grandparent, Etc.Primary Phone Number*Parent/Guardian #2 InformationName* First Last My Relationship to this Child is*Mother, Father, Legal Guardian, Aunt, Uncle, Grandparent, Etc.Email* Secondary Email (optional) Primary Phone Number*Okay to text PRIMARY PHONE if needed?* Yes No Secondary Phone NumberOkay to text SECONDARY PHONE if needed? Yes No Address Street Address Address Line 2 City State ZIP / Postal Code Family InformationPlease select all that apply:* We are new to the Immanuel community I am (and/or spouse is) a member of Immanuel Lutheran Church I am (and/or spouse is) an alum of Immanuel Lutheran School A sibling of this child was previously enrolled at Immanuel Lutheran School A sibling of this child is currently enrolled at Immanuel Lutheran School Your Family's Church Affiliation* Prince of Peace First Methodist Willow Creek Good News in the Neighborhood Harvest None Other How did you hear about our program?* Website Referred by another family Social Media Flyer/Sign Other Child Health InformationDoes your child have any special health needs?*If not, you may write “N/A"Any Known Allergies?* No Yes Allergy InformationList the Known Allergies*Enter the known allergies, separated by commasSymptoms following exposure to a particular material can include: (please check all that apply)* Hives and itchiness on any part of the body Nausea, vomiting, diarrhea Difficulty breathing or swallowing Panic or sense of doom Throat tightness or closing Swelling of any body parts, especially eyelids, lips, face or tongue Fainting or loss of consciousness Coughing, wheezing or change of voice None of the above listed symptoms (please specify below) Please list any additional symptoms here:Please list any general precautions taken at home, daycare, etc.:*Please list emergency measures in response to a reaction (i.e. use of Epi-Pen, etc.)*Is this a severe allergy that requires an Epi-Pen or Auvi-Q injector?* Yes No If your child requires an Epi-Pen, Auvi-Q injector, etc., please be sure to send it with your child and communicate with the teacher.Is there anything else we need to know that will assist us regarding health and safety matters?*Permission to Treat* I agree that the church and school, including its staff, may carry out the emergency measures listed above and that this information will be shared, as necessary, with the teachers, aides, and health care providers.Liability and Publicity ReleaseLiability and Publicity Release For This Child* By checking this checkbox, I am acknowledging that I am signing this form electronically and accept the terms outlined in the Liability and Publicity Release below. LIABILITY RELEASE: In consideration of being allowed to participate in the Events sponsored by Immanuel Lutheran Church & School, Palatine, IL; and in consideration of the benefits derived therefrom, I on my behalf and, if applicable, on behalf of the Minor named hereby release the Northern Illinois District of the Lutheran Church-Missouri Synod, Immanuel Lutheran Church and School and their present and former trustees, officers, directors, boards, shareholders, employees, agents and their heirs, administrators, executors, successors, and assigns release from any and all claims, demands, actions, suits, proceedings, damages, claims and liabilities of any kind, whether known or unknown, which arise from or are connected with my or the Minor’s participation in the event. I am aware that in addition to typical activities such as Bible study, worship, sight-seeing, using public transportation, and meal functions; that I or the Minor may participate in various other activities that may involve some risks, such as service projects and recreational activities. I have read the informational materials about this Event and the site and understand the risks involved in the planned activities. I recognize that the conditions, equipment or standards in some of the places which I or the Minor will travel may not be of the same quality level or standards as the conditions, equipment or standards to which I am accustomed. I realize further that there are certain health risks as well as other risks to me or the Minor and our property. I enter into participation in this Event with knowledge of those risks and acceptance of responsibility for any harm, injury or damage resulting therefrom. If for any reason I am unable to complete my stay at the Event, I assume full responsibility for expenses incurred for my return home. In the event of an emergency, I hereby authorize a leader of this activity, as an agent for me or the Minor, to consent to: any x-ray, examination; medical dental or surgical diagnosis; treatments; hospital care advised and supervised by a physician, surgeon or dentist (as appropriate) licensed to practice under the laws of the state or country where services are rendered, either at a doctor’s office or in a hospital. I expect to be contacted or my family contacted as soon as possible. I understand that this document constitutes a full and complete waiver and release of any and all possible claims for any act or omission, including claims for negligence regarding injury or property damages, arising out of my or the Minor’s participation in the Event. I understand that this release applies to, covers, and includes unknown, unforeseen, unanticipated, and unsuspected risks, damages, losses, or liabilities and the consequences thereof, which result from the matters herein before inferred to as well as those not disclosed and known to exist. The provisions of any state, federal, local or territorial law or statue providing in substance that releases shall not extend to claims or damages which are unknown or unsuspected to exist at the time are hereby expressly waived by me. Furthermore, I do hereby expressly stipulate, and agree to indemnify and hold forever harmless the Northern Illinois District of the Lutheran Church-Missouri Synod, Immanuel Lutheran Church and School, and their agents, servants, successors, assigns, boards, directors, trustees, officers, employees, and other representatives against loss from any and all present or future claims, demands or actions in law or in equity that may hereafter be made or brought by me or the Minor or on our behalf, related to or resulting from any occurrence, act or omission during the Event, or travel to and from the Event. I also hereby release and waive any and all claims for liability against any of the host churches, host institutions and the employees, agents, officers, directors, shareholders, contractors and assigns of such host church or host institution or the owner of any sites that I or the Minor may be at during the Event. By acceptance of participation in the Event, the undersigned agrees to the foregoing and also agrees that the Northern Illinois District of the Lutheran Church-Missouri Synod, Immanuel Evangelical Lutheran Church Palatine, Immanuel Lutheran Church and School, and their employees and other representatives, shall not be liable for loss, damage, injury or inconvenience caused by or resulting from the malfunction of transportation, equipment, strikes, acts of war or insurrection, fire, delays, theft or itinerary or schedule changes or cancellations. PUBLICITY RELEASE: I understand photos, videos and sound recordings of students and children may be used on the Immanuel website, yearbook, brochures or other such media for the purpose of public relations, promotion of Immanuel events, recruitment, student records, historical records or other activities that serve to publicize Immanuel Lutheran Church & School. I further understand that all photos, videos and sound recordings will be taken in a public venue and will not offend Christian or civil standards, and that no written identification of any individual student/child will accompany photos, videos, or sound recordings other than those used for student and historical records. I authorize Immanuel Lutheran Church & School to take photos, videos, and produce sound recordings of the above named student or child and to use such photos, videos and sound records.Release Signature*Printed Name* First Last Date Signed* MM slash DD slash YYYY Δ