Mount Olive Lutheran School Registration 2017-2018
First Name
Student's
Your answer
Middle Name
Student's
Your answer
Last Name
Student's
Your answer
Street Address
Your answer
City, State, Zip
Your answer
Date of Birth
Your answer
Place of Birth
City and State
Your answer
Grade Entering for the 2017-2018 School Year
What is your reason for applying to Mt. Olive Lutheran School
Your answer
How did you hear about Mt. Olive?
Returning families feel free to type "returning"
Your answer
Has your child had any difficulty in school thus far?
Please give a full explanation regarding any "yes" answer
Your answer
Does your child have any physical difficulties?
Please give a full explanation regarding any "yes" answer
Your answer
Does your child require any special attention for learning difficulties?
Please give a full explanation regarding any "yes" answer
Your answer
Has your child ever been retained in a grade?
Please give a full explanation regarding any "yes" answer
Your answer
Has your child ever been promoted more than one grade in a year?
Please give a full explanation regarding any "yes" answer
Your answer
Family Church Affiliation
All children enrolled in this school are encouraged to attend church services regularly. If you don't not have a church affiliation type "none".
Your answer
Are parent and child active, participating members?
Is your child baptized?
If you are not a member of Mt. Olive congregation or another WELS congregation, would you consent to attend adult information classes offered by the church?
If your child is accepted, do you agree to authorize the school to employ such discipline as the school considers wise and expedient for the welfare of the child?
Please list the legal guardian(s) of the above named student applying for enrollment at Mt. Olive
Your answer
Father's First and Last Name
Your answer
Father's Occupation
Your answer
Father's Contact Number
***-***-****
Your answer
Father's E-Mail
Your answer
Father's Driver's License Number
Your answer
Mother's First and Last Name
Your answer
Mother's Occupation
Your answer
Mother's Contact Number
***-***-****
Your answer
Mother's E-Mail
Your answer
Mother's Drivers License Number
Your answer
Parent's marital status
Number of siblings
Ages of siblings
Your answer
Emergency Contact First and Last Name
also authorized to pick-up child
Your answer
Emergency Contact Phone Number
***-***-****
Your answer
Emergency Contact First and Last Name
also authorized to pick-up child
Your answer
Emergency Contact Phone Number
***-***-****
Your answer
Emergency Contact First and Last Name
also authorized to pick-up child
Your answer
Emergency Contact Phone Number
***-***-****
Your answer
Consent for Medical Treatment
I consent to any x-ray examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care under the general or special supervision and upon the advice of or to be rendered by a physician and surgeon licensed under the Medical Practice Act for my child. This authority also extends to any x-ray examination, anesthetic, dental, or surgical diagnosis or treatment and hospital care by a dentist licensed under the Dental Practice Act for my child. I further agree to pay all charges for the dental, medical, or hospital care or treatment.
List any allergies of the child
Please list or type none
Your answer
Physician
Your answer
Physician's Office Number
***-***-****
Your answer
Medical Plan Carrier and Number
Your answer
Dentist
Your answer
Dentist's Office Number
***-***-****
Your answer
Dental Plan Carrier and Number
Your answer
Consent for Pictures
permission for pictures to be taken and posted in the classroom, church, or website
Consent for registration fees and FACTS tuition payments
K-8 $330 registration fee (nonrefundable) / PreK $60 registration fee (nonrefundable) and prompt monthly payments
Student's T-shirt size
(at beginning of the new year)
Your answer
Signature and Date
signature indicates approval of all information on this application including medical treatment, pictures (yes/no), payment and family fees through FACTS, and support of the policies and teachings of Mt. Olive Lutheran School
Your answer
This information does not assure final enrollment, which is subject to the action of the principal and the Board of Education. Children accepted are on a trial basis for one year.
Required
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