Bethesda Lutheran School and Early Learning Center 2025-2026 Registration
Student Name
First Name
Last Name
Grade entering:
Preschool-5th Grade
Parent Signature
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Date
-
Month
-
Day
Year
Date
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Child's Academic Strengths and Other Interests
Academic Challenges to this Point:
Any special health concerns you feel the school should be aware of?
Has child ever been evaluated for:
Learning difficulties
Hearing/vision Problems
Speech Problems
Behavior Problems
Parent/Guardian Signature
Date
-
Month
-
Day
Year
Date
Parent/Guardian Signature
Date
-
Month
-
Day
Year
Date
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Applying for Grade:
School year:
2025-2026
Student's Name
First Name
Last Name
Middle Initial
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Sex:
Male
Female
US Citizen:
Yes
No
Date of Birth:
-
Month
-
Day
Year
Date
Place of Birth:
Baptism Date:
-
Month
-
Day
Year
Date
Home Church:
Resident of School District:
Parents' Marital Status
Married living together
Married living apart
Divorced
Widowed
Other
If divorced, who has legal custody of the student?
Father
Mother
Joint
Father/Guardian's Name
Father/Guardian's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Father's Occupation:
Father's Employer:
Father's Home Phone
Please enter a valid phone number.
Father's Work Phone
Please enter a valid phone number.
Father's Cell Phone
Please enter a valid phone number.
Email
example@example.com
Bethesda Lutheran Church Member?
Yes
No
Not a member of another church
Member of another church
Mother/Guardian's Name
Mother's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mother's Occupation
Mother's Employer
Mother's Home Phone
Please enter a valid phone number.
Mother's Work Phone
Please enter a valid phone number.
Mother's Cell Phone
Please enter a valid phone number.
Mother's Email
example@example.com
Bethesda Lutheran Church Member?
Yes
No
Not a member of another church
Member of another church
Stepfather's Name
Stepfather's Occupation
Stepfather's Phone
Please enter a valid phone number.
Stepmother's Name
Stepmother's Occupation
Stepmother's Phone
Please enter a valid phone number.
Last School Attended
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Sibling 1 Name & Current Grade
Sibling 2 Name & Current Grade
Sibling 3 Name & Current Grade
Sibling 4 Name & Current Grade
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Registration Fees include application fee and materials fee. Each additional child is discounted to $100.
$150 Preschool
$150 Primary Grades K-5
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Student Name
Grade Entering
Date
-
Month
-
Day
Year
Date
Name and Relationship
Phone Number
Please enter a valid phone number.
Name and Relationship
Phone Number
Please enter a valid phone number.
Name and Relationship
Phone Number
Please enter a valid phone number.
Name and Relationship
Phone Number
Please enter a valid phone number.
Child's Name
Medication Allergies:
Medical Conditions:
Medication(s):
Physician:
Phone Number
Please enter a valid phone number.
Alternative Emergency Contact:
Phone Number
Please enter a valid phone number.
Parent Signature
Date
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
If Child has a history of reactions to food or other allergens, please tell us what Plan of Treatment is to be used in case of signs of allergic reaction:
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