Bethel Community Education: 23/24 Enrollment Form, Child 1

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Bethel Community Education does not discriminate on the basis of race, color, national or ethnic origin.

Child's Last Name *

Child's First Name *

Child's Middle Initial

Child's Birthday *

YYYY

Child's Gender *

Female

Male

Child's 2023/2024 Grade Level *

Preschool

Kindergarten

First Grade

Second Grade

Third Grade

Fourth Grade

Fifth Grade

Sixth Grade

Seventh Grade

Eighth Grade

Child's Address (street, city, state, zip) *

Child's Previous School Attended (n/a if not applicable) *

Child's Medical Information (allergies, medical limitations, illnesses) *

Does your child require additional support socially, emotionally, behaviorally, and/or academically? *

Yes

Uncertain

If you answered 'yes' or 'uncertain' in the previous question, please explain.

What additional health and/or medical issues should Bethel Community Education be informed of for your child in order to best support their needs? *

For Bethel Community Education to administer any medication to your child, you must list specific medication, dosage, time (if applicable), and click "I hereby agree to allow Bethel Community Education staff to administer specific medication (i.e. Tylenol, Motrin, Prescription Drugs, Claritin, etc.) to my child. *

I hereby AGREE to allow Bethel Community Education staff to administer specific medication (i.e. Tylenol, Motrin, Prescription Drugs, Claritin, etc.) to my child.

I hereby DISAGREE to allow Bethel Community Education staff to administer specific medication (i.e. Tylenol, Motrin, Prescription Drugs, Claritin, etc.) to my child.

List approved medications not listed above that Bethel Community Education staff can administer. *

Do you have another child to enroll? *

Yes

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