Bertha-Hewitt Early Childhood Education Information Request
For more information regarding Bertha-Hewitt Early Childhood, please fill out the following information. If you have questions filling out the information, please call Lisa Wick at (218) 296-1048
* Required
Child's Full Name
*
Your answer
Child's Birthday
*
MM
/
DD
/
YYYY
Age as of Sept. 1, 2021
*
Your answer
Mother's Name
Your answer
Father's Name
Your answer
Child Lives with (choose one):
Both Parents
Mother
Father
Guardian
Other
Mailing Address
Your answer
Physical Address (if different from mailing)
Your answer
Home Phone #
Your answer
Contact Email Address
*
Your answer
Mothers Cell #
Your answer
Okay to correspond via texting with Mother's Cell?
Yes
No
Clear selection
Father's Cell #
Your answer
Okay to correspond through texting with Father's Cell?
Yes
No
Clear selection
Siblings (Names and grade) - ***IMPORTANT - Please list younger siblings also
Your answer
I am interested in receiving information regarding (please see detailed information under specific program section of the website):
Early Childhood Family Education (ECFE)
School Readiness (SR)
Early Childhood Special Education (ECSE)
Early Childhood Screening (ECS - Preschool Screening)
Head Start (Eligibility-based - income, special needs, family circumstances)
Unsure - I would like a phone call to discuss all options available
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