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Christ Our Rock Lutheran High School

New Student Application

New Student Application
Student Information
Student's Name*
First Last
Name student goes by
Birth Date*
Date Format: MM slash DD slash YYYY
Sex*
- Male
- Female
Student Entrance Grade*
- 9
- 10
- 11
- 12
For School Year*
- 2025-26
Address*
Street Address City State / Province / Region ZIP / Postal Code
Home Phone*
Social Security Number
Ethnicity*

(if bi-racial, please list both races – we are required to report this information to the ISBE)
Family Information
Father’s Name*
First Last
Address*
Same as child's address

Street Address City State / Province / Region ZIP / Postal Code
Home Phone*
Work Phone
Cell Phone*
Employer
Occupation
Parent Email*
Mother’s Name*
First Last
Address*
Same as child's address

Street Address City State / Province / Region ZIP / Postal Code
Home Phone*
Work Phone
Cell Phone*
Employer
Occupation
Parent Email*
Other Children in Family
Name Age

Click + icon to add more
Parents Marital Status:*
- Together
- Separated
- Divorced
- Widowed
If parents are separated, who has custody?
Other parent / guardian 1 (step parents, etc.) Name
First Last
Relationship
Home Phone
Work Phone
Cell Phone
Email
Employer
Occupation
Resides with student?
- Yes
- No
Other parent / guardian 2 (step parents, etc.) Name
First Last
Relationship
Home Phone
Work Phone
Cell Phone
Email
Employer
Occupation
Resides with student?
- Yes
- No
Other Emergency Contact*
Name Phone 1 Phone 2
School Information
Current / Previous School*
Dates attended*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Principal*
Phone*
Email*
Church Information
Are you the member of a church?*
- Yes
- No
Church Membership*
Denomination*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Pastor*
Phone*
Email*
Years attended*
Student’s baptism date (mm/dd/yyyy)*
Financial Information
Person(s) responsible for paying tuition*
Tuition Assistance*
Yes, we are applying for Tuition Assistance (a separate application must be completed).

Upon acceptance of this application, CORLHS will contact you to discuss payment options.

Statement of Intent

We, as parents, desire a quality, Christ-centered, secondary education for our child, and believe Christ Our Rock Lutheran High School will provide this type of education. We understand that education includes a partnership between the parents and the school. Therefore, we will actively support the school and our child’s education and will keep open the lines of communication between school and home. We hereby acknowledge that acceptance and continuation of attendance at CORLHS is dependent upon both the students and parents living a lifestyle that is in accordance with Biblical values as taught and promoted by this school.
Application Fee
Price: $50.00
Parent Signature*
Date*
Date Format: MM slash DD slash YYYY
Statement of intent
I want to attend Christ Our Rock Lutheran High School and will do my best to be an asset to the student body.
Student Signature*
Date*
Date Format: MM slash DD slash YYYY

My above signature signifies that I understand that photographs of applicant taken at school or school sponsored activities may be used for publicity of Christ Our Rock Lutheran High School. According to FERPA (1974), information will not be disclosed to unprivileged individuals or groups and information will be given to specific individuals only with proper consent.

My above signature signifies that I give permission to include our name, address, and phone number in the CORLHS directory.
We will actively support the school and our child’s education and will keep open the lines of communication between school and home. We hereby acknowledge that continuation of attendance at CORLHS is dependent upon both the student and parents living a lifestyle that is in accordance with Biblical values as taught and promoted by this school and agree to abide by the Policy and Procedures as approved by the Association Board of Directors and contained in the Parent/Student Handbook.

My above signature signifies that I give CORLHS permission to obtain the recommendations required as part of the application process.

Christ Our Rock Lutheran High School admits students of any race, color, sex, and national or ethnic origin to all the rights, privileges, programs and activities generally accorded or made available to students at the school. It does not discriminate on the basis of race, color, sex, or national or ethnic origin in the administration of its educational policies, admission policies, financial assistance, and other school administered programs.

Please return completed Application for Admission with the $50.00 application fee to:

Christ Our Rock Lutheran High School
9545 Shattuc Road
Centralia, IL 62801
Please contact us at (618) 226-3315 with any questions.

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