Welcome to our online application for our Early Childhood Programs.To enter our three old preschool program your child needs to be three before September 1. To enter our four year old preschool program your child needs to be four before September 1.To enter our 5K Kindergarten your child needs to be five before September 1. Please fill in the following information and submit it.


CHILD INFORMATION

Child's Name: (*)

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Address: (*)

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City: (*)

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State: (*)

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Zip Code: (*)

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Date of Birth: (*)

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Child's Home Phone: (*)

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Name Child goes by:

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Gender: (*)
MaleFemale
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Select One (*)
Three year old preschoolFour year old preschool5K/Kindergarten
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E-Mail Address:

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FAMILY INFORMATION

Father's Full Name: (*)

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Father's Address: (*)

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Father's Phone #: (*)

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Father's Occupation:

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Place of Employment(if unemployed write unemployed) (*)

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Father's Work Phone #:

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Mother's Full Name: (*)

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Mother's Address (*)

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Mother's Phone #: (*)

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Mother's Occupation: (*)

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Place of Employment(if unemployed write unemployed) (*)

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Mother's Work #:

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CHURCH MEMBERSHIP

Church Affiliation: (*)
Bethany
Other WELS Church
Other Christian Church
Other
No Church Home

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If not a member of Bethany, please tell us the name of your church

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Please tell us the city or location of your church:

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Your Pastor's name:

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Your Pastor's phone #:

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The following questions are asked in order that I may get to know your child's interests better. By doing this, I am hoping to be able to teach each child's area of interest. ALL INFORMATION WILL BE KEPT CONFIDENTIAL! THANK YOU.


HOME INFORMATION

Does your child normally eat breakfast?
yesno
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How many hours a day does your child watch TV?
none12345more
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What is your child's favorite program to watch?

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Does your child play video games?
YesNo
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On a computer?
YesNo
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What kind of responsibilities does your child have around the house?

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Does your child have any special interests, hobbies, or collections?

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What time does your child normally go to bed?

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Other adults who play an important role in your child's life:

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Names of brothers and sisters:

Name

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Age:

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In home with child?
YesNo
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Name:

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Age:

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In home with child?
YesNo
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Name:

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Age:

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In home with child?
YesNo
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Name:

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Age:

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In home with child?
YesNo
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ACADEMIC INFORMATION

Has your child had a previous group interaction or preschool experience?

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How does your child feel about books and reading?

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Who reads aloud to your child?

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What kind of books does he/she like?

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Does your child have a library card?
YesNo
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What kind of writing does your child attempt to do?
DrawingSymbolsLettersNotesListsStories
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PICK UP INFORMATION

Persons authorized to pick up your child: (*)

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Persons NOT authorized to pick up your child:

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MEDICAL INFORMATION


In case of a serious accident or illness at school, the school principal will send your child to the hospital of your choice. Please select your choice below. The legal responsibility for ambulance conveyance expenses and for medical expenses incurred on behalf of your child is a parental one

Please select the hospital
Watertown Regional Medical Center
Hartford Memorial Hospital
BeaverDam Community Hospital
Oconomowoc Memorial Hospital
Aurora Summit Hospital

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Does your child have allergies?
YesNo
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If yes, please list: (*)

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Family Physician: (*)

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Phone #

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Family Dentist:

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Phone #

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Are there any medical problems that we should be aware of?

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List special food or eating instructions:

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How does your child communicate to us that he or she needs to go to the bathroom? Any special words or signs or actions that we should be aware of?

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Does your child have any bowel or bladder irregularities?

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BEFORE AND AFTER CARE

Bethany Lutheran School offers a before and after program for students of our school in 3K - 8th grade. Before Care is 6:00 to 8:00 a.m. - After Care is 3:30 - 6:00 p.m. Please indicate below if this interests you.
yesno
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While your child is enrolled in Bethany Learning Center and/or Before and After Care he/she will be involved in activities for which we need your permission.

I give my permission for my child to go on walks with the teachers in the nearby neighborhood.
yesno
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I give my permission for my child's picture to be used in promotional materials such as-- Website, brochures, invitational mailures etc.
yesno
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Please type in the characters you see:

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