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Day School FormRobert Elliott2024-09-27T11:05:08-05:00

St. Luke's Day School

Step 1 of 5

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  • Part 1 - Parent and Child Information

  • MM slash DD slash YYYY
  • Landline only; leave blank if not applicable
  • Note: Additional documentation will be required if parents are separated or divorced.
  • If Child Is Adopted (optional)
  • Family Culture (optional)

  • Part 2 - Medical Information & Health History

  • Note: An Allergy Action Plan is required for children with diagnosed allergies and a prescribed EPI pen. If no EPI, Allergy Action Plan is helpful. This paperwork will be due no later than one week prior to child’s first day of school.
  • In the event I cannot be reached to make arrangements for emergency medical attention, I authorize the facility director or person in charge to take my child to the recommended hospital or to his/her doctor. I give my consent for necessary emergency treatment.

  • Part 3 - Authorization for Pick Up


    List all persons authorized to pick your child up from school. Both parents must be included.

  • I authorize only the persons on this list to pick up my child from St. Luke’s Day School. Persons unknown to the teachers must present a photo ID.

  • Part 4 - Introduce Us to Your Child

  • General Information - Please answer for all children:

  • Part 5 - Parent Permission and Payment of Fees Agreement


  • Health and Safety
  • · I give my consent for Day School staff to apply any of the following first aid products to my child as needed: antibiotic ointment, 1% hydrocortisone anti-itch cream, antiseptic wipe, latex-free bandage.

    · I give my consent for information about my child’s allergies to be posted in the classroom, if applicable.
  • Program Activities
  • · I give my permission for my child to use all play equipment and participate in all school activities.

    · I give my permission for my child to participate in water activities using water tables and sprinklers.

    · I give my permission for photographs of my child to be used in the classroom, on class web pages (restricted access), and for SLDS use. (Children’s faces are not displayed on social media, and names are not attached to images outside the classroom.)
  • Tuition and Fees
  • · I hereby agree to pay my child’s tuition on or before the first of each month. If I have provided payment information (ACH or credit card), I understand that tuition and fees will be charged according to the published schedule.

    · I understand that a fee of $20 will be charged if my tuition payment is late (after the fifth of the month), and that my child may be asked to leave the program if the tuition is paid late thereafter.

    · I understand a late fee of $20 will be charged for returned checks and declined ACH transactions.

    · I understand that a fee of $1.00 per minute will be charged for late pick-up.
  • I give my consent for my child’s name, parents, and contact information (address, primary phone, primary email) to be published in the school directory. The directory is distributed to Day School families and staff only.

  • My signature verifies that all adults in my child’s family agree to the above terms for payment of fees and parent permission, and agree to comply with the rules and regulations of St. Luke’s Day School as outlined in the Family Handbook.
  • MM slash DD slash YYYY
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