Application

LIGHTHOUSE CHILDREN’S HOME APPLICATION FOR ADMISSION

Lighthouse Children’s Home - 7771 Mahan Drive, Tallahassee, FL 32309 (850) 877-3778

Fax application to: (850) 656-8249 or Email to: office@lighthousechildrenshome.com

The Lighthouse Children’s Home makes no promise that the submission of any application to the Lighthouse assures placement for the child in our program. All applications must first be reviewed by the Lighthouse Administration. Then those applicants deemed likely candidates for placement will be given an interview before final determination of their placement is made. THIS IS A PERMANENT RECORD. All questions must be answered and answered truthfully. Giving false or misleading information and/or omitting information pertinent to the child may cause the child to either not be approved for the program or to be expelled from the Lighthouse Children's Home if approved and the information is revealed after admission. If information is unknown, every effort should be made to obtain it. This record will be very valuable in working with the child. If a question is not applicable, please mark N/A. Use additional paper if necessary.

TODAY’S DATE: / /

General Information About THE PARENT(S) / GUARDIAN(S)

Name of person making application:

Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Email:

Your place of employment:

Address:

City:

State:

Zip:

Work Phone:

What is your relationship to the child? Birth ParentAdoptive ParentStep ParentGuardian

Other - explain:

Select which of these apply to you: Sole-custodyJoint-custodyTemporary Guardian

List the information of anyone else who has legal custody and/or visitation rights for this child

Name:

Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Email:

What is their relationship to you? HusbandEx-husbandWifeEx-wife

List the information of anyone else who knows you and this child so that we may call them as a reference:

Name:

Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

What is the name and location of your home church?

General Information About THE Child THIS APPLICATION IS FOR

Name:

Age: Birth date:

Ethnicity: WhiteAfrican-AmericanHispanic

Other:

Siblings - list their names, ages, and relationship (brother, sister,
half-brother, step-sister, etc….)

EDUCATION

What is the last grade this child passed?

What is her current grade?

Is this child currently passing or failing? PASSINGFAILING

Has this child been held back or failed any grade? NoYes-Held BackYes- Failed

Which Grade?

Has this child been skipping school? Number of Times:

Has this child ever been suspended? Number of Times: Reason:

Has this child ever been expelled? Number of Times: Reason:

What is the name and address of the school this child is currently enrolled in?

Has this child ever been suspected of or diagnosed with DYSLEXIA?

Has this child ever been suspected of or diagnosed with any other learning disabilities?

Has this child ever been in special education classes or alternative classes?

Is this child on an I.E.P., 504 plan, or similar education plan?

Does this child require any other special accommodations for their education?

If yes or uncertain to any of the above, please explain:

List any plans this child has for their educational future such as college, a particular career or trade, or military service.


GENERAL HEALTH / EMOTIONAL AND MENTAL CONDITION OF THE CHILD

Does this child have any physical disabilities or limitations?

If yes, explain:

Has this child ever been suspected of, diagnosed with, and/or received counseling or treatment for any of the following:

Attention Deficit Disorder (ADD)

Attention Hyperactive Deficit Disorder (ADHD)

Mood disorders

Bipolar

Depression

Oppositional Defiance Disorder (ODD)

Schizophrenia

Post-Traumatic Stress Disorder (PTSD)

Reactive Attachment Disorder (RAD)

Self-harm and/or suicide attempts

Autism/Asperger Syndrome

Eating disorders

Emotional or physical abuse

Sexual abuse and/or rape

Substance abuse

Sleep disorders

Pregnancy

Abortion

If yes to any of the above, please explain:

List all current and past counsellors, treatment/therapy centers,
physicians, and mental health professionals who had treated any of the
above conditions.

List all current or past prescriptions, over-the-counter medicines, and
natural remedies used to treat any of the above conditions.

BEHAVIOR AND CHARACTER OF THE CHILD

Check all areas that describe your child:

Defiant and disrespectful

Outbreaks of temper or physically violent to others, fighting - explain:

Mistreatment of pets or other animals - explain:

Arson, vandalism, destruction of property - explain:

Lying and/or secretive behavior

Manipulative and/or controlling

Stealing, shoplifting

Association with wrong crowd, poor choice of friends

Has been involved in witchcraft or related activities - How long ago and
for how long:

Is fascinated with "dark" things such as black clothing, hair, makeup, and
"dark" pictures, movies, and internet sites

Has run away Number of times How long are they usually gone

Has a poor physical appearance and/or weight problem

Tattoos and/or piercings - list what and where:

Sexually active

Homosexual or bi-sexual

Pornography and/or sending/receiving inappropriate pictures and texts
("sexting")

Are there any past or current situations involving this child and/or their
family whereby child protective services is/was involved?

If yes, explain:

Has this child ever been arrested and/or placed on probation?

If yes, explain:

List the positive behaviors and characteristics the girl exhibits, as well
as any skills (such as music, art, or sports), hobbies, and special
interests of the girl:

What specifically is your hope and expectation of the Lighthouse and the
child if they were to be approved for our program?


****IF THERE IS ANYTHING ELSE YOU FEEL WE SHOULD KNOW OR ANY FURTHER
EXPLANATION FOR ANYTHING PREVIOUSLY MENTIONED, USE THE LAST PAGE OF THE
APPLICATION AND ANY ADDITIONAL PAGES NECESSARY


ADDITIONAL INFORMATION

 

DOWNLOAD APPLICATION

 

Admission Requirements


1) An application must be filled out and sent back to the Lighthouse for review.


2) An on-campus interview (or Skype for those who live long distances) with the girl and parent/guardian will then be set up whenever possible. At the interview the family will meet our resident girls, be shown around the property, and have the entire program explained to them. If approved, the family will then be given all of the necessary paperwork required for the child to be admitted and a date will be set for the girl’s admission.


3) A Medical Questionnaire must be filled out by a health care provider and the results must be in before the girl may enter the program.


Click on the link above to download an application or call us at (850) 877-3778 to have an application emailed, mailed, or faxed to you. If you have any questions about the application please call our office and ask for the Executive Director.


FAX THE COMPLETED APPLICATION TO: 850-656-8249


OR SCAN AND EMAIL THE COMPLETED APPLICATION TO: office@lighthousechildrenshome.com


OR MAIL THE COMPLETED APPLICATION TO:


Lighthouse Children’s Home
7771 Mahan Dr.
Tallahassee, FL 32309