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:

Which of these apply?

Sole Custody
Joint Custody
Temporary Guardian

Other Individual With Legal Custody and/or Visitation Rights

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

Yes
No

What is their relationship to you?

Please explain their relationship to you:

Name

First

Middle

Last

Email

Confirm Email

Address

Address Line 1

City

State

Zip Code

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

Alt. 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

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 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 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 any of the above, 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.

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

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

Behavior and Character of the Child

Please check all that describe your child:

Please briefly describe the outbreaks of temper or 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, vandalism, destruction of property:

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

Regarding the witchcraft or related activities, how long ago and for how long?

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

How many times did this child run away, and how long were they gone?

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

Did a parent or guardian approve of the tattoo and/or piercings??

Parent/guardian approved of tattoo and/or piercing
Parent/guardian did not approve of the tattoo and/or piercing

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

Please briefly describe the tattoos and/or piercings this child has. Include what they are and where:

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

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

No
Yes

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.

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

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.

Sign Form

Printed Name

Today's Date

Signature

Clear Signature

Admissions Application

Before You Apply

Parent/Guardian Information

Parent/Guardian Employment Information

Applicant's Relationship to the Child

Other Individual With Legal Custody and/or Visitation Rights

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

Sign Form

Honor & Memorial Giving Form

Your Billing Info

Adopt-A-Teen Renewal Form

Your Info

Adopt-A-Teen Sign-up Form

Your Info

Secure Donation Form