Welcome to Bethany Lutheran School's
Online Application Form
Please fill out the form and click on the submit button. If you have any questions, please call us at 920-349-3244.
Parent's Information
Father's Full Name:
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Mother's Full Name:
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Street Address: (*)
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City: (*)
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State: (*)
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Zip Code: (*)
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Home Phone:
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Father's Work:
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Father's Cell:
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Mother's Work:
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Mother's Cell:
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E-Mail Address: (*)
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Church Membership
Church Affiliation: (*)
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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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Child's Information
First Child
First Child's Full Name: (*)
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Date of Birth: (*)
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What grade will your child attend in the 2012-2013 school year? (*)
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Does your child have any allergies?
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If this child has any allergies, please list the allergies and describe the reaction. Also, please indicate any special request you wish to make to help us aid your child in case of an emergency.
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Second Child
Second Child's Full Name:
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Date of Birth:
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What grade will your child attend in the 2012-2013 school year? (*)
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Does your child have any allergies?
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If this child has any allergies, please list the allergies and describe the reaction. Also, please indicate any special request you wish to make to help us aid your child in case of an emergency.
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Third Child
Third Child's Full Name:
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Date of Birth:
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What grade will your child attend in the 2012-2013 school year? (*)
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Does your child have any allergies?
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If this child has any allergies, please list the allergies and describe the reaction. Also, please indicate any special request you wish to make to help us aid your child in case of an emergency.
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Fourth Child
Fourth Child's Full Name:
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Date of Birth:
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What grade will your child attend in the 2012-2013 school year? (*)
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Does your child have any allergies?
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If this child has any allergies, please list the allergies and describe the reaction. Also, please indicate any special request you wish to make to help us aid your child in case of an emergency.
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Emergency Information
First Contact
First Contact's Name: (*)
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First Contact's Relationship with the Child: (*)
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First Contact's Address: (*)
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First Contact's Home Phone:
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First Contact's Cell Phone:
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Second Contact
Second Contact's Name: (*)
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Second Contact's Relationship with the Child: (*)
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Second Contact's Address: (*)
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Second Contact's Home Phone:
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Second Contact's Cell Phone:
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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.
Select the hospital (*)
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Family Physician's Name: (*)
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Physician's Phone: (*)
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Physician's Address: (*)
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Physician's City: (*)
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Health Insurance Name:
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Health Insurance Policy #:
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Dentist's Name:
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Dentist's Phone:
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Dentist's Address:
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Dentist's City:
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Dental Insurance Name:
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Dental Insurance Policy #:
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*Please notify the school whenever any of the above information changes*
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