K-8 New Student Enrollment Agreement 2022-2023

Student Name *

First Name Last Name

Allergies

Medications

Purpose of medication and does it need to be taken during school hours

Father's/Legal Guardian's Name

First Name Last Name

Father's Cell Phone Number

Please enter a valid phone number.

Father's Work Phone Number

Please enter a valid phone number.

Father's Email

example@example.com

Father's Occupation/Place of Employment

Mother's/Legal Guardian's Name

First Name Last Name

Mother's Cell Phone Number

Please enter a valid phone number.

Mother's Work Phone Number

Please enter a valid phone number.

Mother's Email

example@example.com

Mother's Occupation/Place of Employment

Name and age of siblings

	Name	Age
Sibling 1
Sibling 2
Sibling 3
Sibling 4

Student resides with: *

Both Parents Mother Father Grandparents Mother/Stepfather Father/Stepmother Other

If living in separate households, how much time is spent with Mother:

Mother

Legal Custody (Mother)?

Yes No

Yes, how much?

Mother

If living in separate households, how much time is spent with Father:

Father

Legal Custody (Father)?

Yes No

Yes, how much?

Father

If there is legal custody involved, we need a copy of court papers, as we only honor court documentation.

If child has two households, we need the complete addresses for each household: Mother's Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

If child has two households, we need the complete addresses for each household: Father's Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Other family members living in household?

Are there any unusual factor in this child's life? (Ex. death in the family, multiple residences, etc.)

Last School Attended *

Dates/Years Attended

Address of last school attended

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Grade Level *

*

Passed Retained

Last teacher

Has your child attended another school before the previous one listed above?

School Attended

Address of school attended

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Grade Level

Passed Retained

Years/Dates

Have they ever repeated a grade? *

Yes No

If yes, please explain

Have they ever been dismissed, suspended or expelled? *

Yes No

If yes, please explain

Have they had a history with behavior or academic challenges? *

Yes No

If yes, do they have an IEP or 504 plan?

Yes No

With which district?

Please explain

Please provide copies of paperwork to Mrs. Huff before your appointment date.

Do they have any other limitations or handicaps? *

Yes No

If yes, please explain

Share with us your strengths and challenges. What makes your child unique? *

Does your family attend church together? *

Yes No

If yes, which church?

How often?

Regularly Occasionally Seldom

Who attends?

Are you a member of your church?

Yes No

How did you hear about Bethany School?

Bethany Church Website Advertisement Live in the area Family or friend Other

If recommended by another, please share their name below

Please give a statement about why you wish to send your child to Bethany School

If your child is entering middle school (6th, 7th, or 8th grade), please print and fill out the supplemental middle school reference form and submit to the school office.

Supplemental Middle School Reference Form

In signing this application , you are agreeing to the ternms of agreement listed on the enrollment form and those listed below.

I ALSO UNDERSTAND THAT:

-Registration will be based upon prior school conduct, academic record, attendance record, and other pertinent factors.

-The administration has full discretion in the dicipline of my child in accordance to the school policy.

-Students entering Kindergarten must be 5 years old by September 1st.

-All paperwork from previous schools and up to date information about IEP/504 plans must be submitted before admission.

I AGREE TO BE RESPONSIBLE FOR THE ABOVE FINANCIAL OBLIGATIONS AND SCHOOL POLICIES

Mother's/Legal Guardian's Signature

Clear

Father's/Legal Guardian's Signature

Clear

K-8 New Student Enrollment Agreement 2022-2023

Parent Information

Terms of Agreement

NEW STUDENT INFORMATION

Church Attendance

Other Information

Payment