LightHouse Summer Camp

Page 1

Application for Admission

Student Information

All information must be provided for this application to be considered. Applications containing inaccurate or untruthful information will be grounds for immediate dismissal.

Child's First Name

Child's Middle Name

Child's Last Name

Child's Birth Date

Child's SSN

Address 1

Address 2

City

Zip Code

Family Information

Father's Information

Father's First Name

Father's First Name :: If you are a single parent enter 'Single' for the missing spouse.

Father's Last Name

Father's Last Name :: If you are a single parent enter 'Single' for the missing spouse.

Address 1

Address 2

Zip Code

Home Phone

Home Phone :: Enter only numbers, no dashes (2223334444)

Cell Phone

Cell Phone :: Enter only numbers, no dashes (2223334444)

Personal Email

Where Employed

Where Employed :: If currently not working enter either 'unemployed' or 'stay at home parent'.

Work Phone

Work Phone :: If 'unemployed is selected above, enter your home phone, (2223334444)

Work Email

Mother's Information

Mother's First Name

Mother's Last Name

Address 1

Address 2

Zip Code

Home Phone

Home Phone :: Enter only numbers, no dashes (2223334444)

Cell Phone

Cell Phone :: Enter only numbers, no dashes (2223334444)

Personal Email

Where Employed

Where Employed :: If currently not working enter either 'unemployed' or 'stay at home parent'.

Work Phone

Work Phone :: If 'unemployed is selected above, enter your home phone, (2223334444)

Work Email

Who has legal custody of the child?

Are both parents allowed to pick up this child?

If selected 'No' please explain

A current copy of all legal documents stating visitation rights and custody must be kept on file in the office. Otherwise, the school is obligated to release this child to either parent. It is the sole responsibility of the parent to provide the school with any changes or updated legal documents.

Full Name of person responsible for paying tuition and fees

Student Background

Has the applicant had any discipline problems or been suspended or expelled from another program?

If yes, please explain

Does the applicant have any emotional, physcal or mental problems or handicaps that may affect activities or progress?

If yes, please explain

Has the applicant been diagnosed as being ADD or ADHD?

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LightHouse Summer Camp

Application for Admission

Student Information

Family Information

Father's Information

Mother's Information

Student Background

"The school-choice issue is not about public versus private; it's about choice. It's about knowing what works well for my family and being able to make that choice for them." -- Parent of a McKay Scholarships Student