Admissions Application

Parent/Guardian Information

Name

First

Middle

Last

Email

Confirm Email

Primary Phone

Secondary Phone (optional)

Address

Address Line 1

City

State

Zip Code

Parent/Guardian Employment Information

My employment status:

Employer's Address

Address Line 1

City

State

Zip Code

Applicant's Relationship to the Child

What is your relationship to the child?

Please explain your relationship to the child:

When did you gain custody of the child?

Do you have legal authority to place the child?

Yes
No

Which of these apply:

Sole Custody
Joint Custody
Temporary Custody

Please briefly explain the temporary arrangement:

List The Other Individual With Legal Custody Rights

Name

First

Middle

Last

Email

Confirm Email

Primary Phone

Secondary Phone

Address

Address Line 1

City

State

Zip Code

What is their relationship to you?

Please explain their relationship to you:

Other parent/legal guardian employment status:

Employer's Address

Address Line 1

City

State

Zip Code

Other Parent/Guardian Relationship to the Child

What is their relationship to the child?

Please explain their relationship to the child:

When did they gain custody of the child?

Reference

Please list one person who knows both you and the child so we can contact them as a reference.

Reference Name

First

Last

Reference Email

Email

Confirm Email

Reference Phone

Reference Secondary Phone (Optional)

Reference Address

Address Line 1

City

State

Zip Code

Your Home Church Info

Do you have a home church?

Yes
No

Does the child attend church with you?

Child attends
Child does not attend

Are you a member of the church or just attending?

I'm not a member
I am a member

How long have you been attending this church?

Church Name

Pastor's Name

Church or Pastor's Phone Number

Church Address

Address Line 1

City

State

Zip Code

Is your Pastor aware of the situation with your child?

Yes
No

May we call your Pastor for a reference?

Yes
No

Information About the Child

The remainder of this application will be information about the child you are wishing to place in our care. Please answer as truthfully and thoroughly as you can.

Child's Name

First

Middle

Last

Child's Age

Child's Birthday

Child's Ethnicity

Child's ethnicity description:

Child's Sibling(s)

Does the child have any siblings?

Yes
No

Please list sibling(s).

Name, age, & relationship (brother, sister, half-brother, step-sister, etc….)

Child's Education

Is the child currently enrolled in school?

Yes
No

School Name

School Address:

Address Line 1

City

State

Zip Code

Last grade the child completed?

Child's current grade:

Child is currently:

Has this child been held back or failed any grade?

No
Yes - held back
Yes - failed

Has this child been skipping school?

No
Yes

Has this child ever been suspended?

No
Yes

Has this child ever been expelled?

No
Yes

Child's Learning Abilities

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

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

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

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 questions about the child's learning abilities, please explain:

There will be an opportunity for longer explanations at the end of this form, if need be.

Please list any plans this child may have for their educational future, such as college, a particular career or trade, or military service:

There will be an opportunity for longer explanations at the end of this form, if need be.

General Health - Emotional and Mental Condition of the Child

Does this child have any physical disabilities or limitations?

No
Yes

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

If yes to pregnancy or abortion, please explain:

There will be an opportunity for longer explanations at the end of this form, if need be.

Please list all current and past counsellors, treatment/therapy centers, physicians, and mental health professionals who have treated any of the above conditions:

There will be an opportunity for longer explanations at the end of this form, if need be.

Is your child currently on any prescription or over-the-counter medications?

Yes
No

Add another medication?

Yes
No

Add another medication?

Yes
No

Add another medication?

Yes
No

Add another medication?

Yes
No

Behavior and Character of the Child

Please check all that describe your child:

Please briefly describe the defiance:

There will be an opportunity for longer explanations at the end of this form.

Please briefly describe the disrespectful behavior:

There will be an opportunity for longer explanations at the end of this form.

Please briefly describe the outbreaks of temper:

There will be an opportunity for longer explanations at the end of this form.

Please briefly describe the physical violence with others:

There will be an opportunity for longer explanations at the end of this form.

Please briefly describe the mistreatment of pets or other animals:

There will be an opportunity for longer explanations at the end of this form.

Please briefly describe the arson:

There will be an opportunity for longer explanations at the end of this form.

Please briefly describe the vandalism:

There will be an opportunity for longer explanations at the end of this form.

Please briefly describe the lying behavior:

There will be an opportunity for longer explanations at the end of this form.

Please briefly describe the secretive behavior:

There will be an opportunity for longer explanations at the end of this form.

Please briefly describe the manipulative behavior:

There will be an opportunity for longer explanations at the end of this form.

Please briefly describe the controlling behavior:

There will be an opportunity for longer explanations at the end of this form.

Please briefly describe the stealing/shoplifting:

There will be an opportunity for longer explanations at the end of this form.

Please briefly describe the being associated with the wrong crowd/poor friend choice:

There will be an opportunity for longer explanations at the end of this form.

Please briefly describe the witchcraft & related activities:

There will be an opportunity for longer explanations at the end of this form.

Regarding the witchcraft & related activities, how long ago did this start?

There will be an opportunity for longer explanations at the end of this form.

Please briefly describe the situation when the child ran away:

Please briefly describe the poor physical appearance:

There will be an opportunity for longer explanations at the end of this form.

Please briefly describe the weight problems:

There will be an opportunity for longer explanations at the end of this form.

Did a parent or guardian approve of the tattoo?

Parent/guardian approved of tattoo
Parent/guardian did not approve of the tattoo

You can explain more details in the "additional info" section at the end of this form.

Did a parent or guardian approve of the piercings?

Parent/guardian approved of the piercing
Parent/guardian did not approve of the piercing

You can explain more details in the "additional info" section at the end of this form.

Please briefly describe the child's situation regarding homosexuality:

There will be an opportunity for longer explanations at the end of this form.

Please briefly describe the child's situation regarding bi-sexuality:

There will be an opportunity for longer explanations at the end of this form.

Please briefly describe the child's situation regarding pornography:

There will be an opportunity for longer explanations at the end of this form.

Please briefly describe the child's situation regarding sending/receiving inappropriate pictures and texts ("sexting"):

There will be an opportunity for longer explanations at the end of this form.

Please briefly describe the child's situation regarding fascination with "dark" things:

There will be an opportunity for longer explanations at the end of this form.

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

No
Yes

Please explain the situation with child protective services:

There will be an opportunity for longer explanations at the end of this form, if need be.

Has this child ever been arrested?

Yes
No

Has this child ever been placed on probation?

Yes
No

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:

There will be an opportunity for longer explanations at the end of this form, if need be.

Has there been a specific time or event that may have contributed to the onset of this behavior?

Yes
No

Please explain:

Final Details

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

There will be an opportunity for longer explanations at the end of this form, if need be.

You can provide any additional details or information here:

If you need more space, please use the file upload option below to attach a word document.

File Upload

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Please upload any relevant documents you may want to share with us.

By clicking below, I attest that all information provided is true and accurate to the best of my knowledge. Nothing has been overstated or understated.

Yes, all the information provided is true and accurate to the best of my knowledge, with nothing being overstated or understated

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Admissions Application

Before You Apply

Parent/Guardian Information

Parent/Guardian Employment Information

Applicant's Relationship to the Child

List The Other Individual With Legal Custody Rights

Other Parent/Guardian Relationship to the Child

Reference

Your Home Church Info

Information About the Child

Child's Sibling(s)

Child's Education

Child's Learning Abilities

General Health - Emotional and Mental Condition of the Child

Behavior and Character of the Child

Final Details

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