Admissions Application

The Lighthouse Children’s Home makes no promise that the submission of any application 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.

Proceed

Admissions Application

The Lighthouse Children’s Home makes no promise that the submission of any application 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.

Proceed

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.

If you have any questions or need help, please call us at: 850-877-3778.

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Parent/Guardian Information

Name
Email
Address

Parent/Guardian Employment Information

My employment status:

Applicant's Relationship to the Child

What is your relationship to the child?
Which of these apply?

Other Individual With Legal Custody and/or Visitation Rights

Does anyone else have legal custody and/or visitation rights for this child?

Reference

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

Your Home Church Info

Do you have a home church?

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
Child's Birthday

Child's Sibling(s)

Does the child have any siblings?

Child's Education

Is the child currently enrolled in school?
Has this child been held back or failed any grade?
Has this child been skipping school?
Has this child ever been suspended?
Has this child ever been expelled?

Child's Learning Abilities

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

Behavior and Character of the Child

Please check all that describe your child:
Are there any past or current situations involving this child and/or their family whereby child protective services is/was involved?
Has this child ever been arrested and/or placed on probation?
There will be an opportunity for longer explanations at the end of this form, if need be.

Final Details

There will be an opportunity for longer explanations at the end of this form, if need be.
If you need more space, please use the file upload option below to attach a word document.
Click or drag files to this area to upload. You can upload up to 5 files.
Please upload any relevant documents you may want to share with us.

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