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Enrollment Application

Date of Application*

Student Information

Student first name*

Student last name*

Grade*

Student DOB*

Gender*

Male

Female

Race*

Child resides with*

Both parents

Father

Mother

Other

Father/ Gaurdian Information

Father/Guardian Name

Father/Guardian Phone Number

Father/Guardian Email

Father/Guardian Address

Father/Guardian City/State

Father/Guardian Zip

Father/Guardian Employer

Father/Guardian Employer Phone

Father/Guardian Employer Address

Father/Guardian Church Affiliation

Father/Guardian Religious Faith

Father/Guardian Church City/State

Mother/ Guardian Information

Mother/Guardian Name

Mother/Guardian Phone Number

Mother/Guardian Email

Mother/Guardian Address

Mother/Guardian City/State

Mother/Guardian Zip

Mother/Guardian Employer

Mother/Guardian Employer Phone

Mother/Guardian Employer Address

Mother/Guardian Church Affiliation

Mother/Guardian Religious Faith

Mother/Guardian Church City/State

Emergency Contact Information

Emergency Contact Name*

Emergency Contact Phone*

Emergency Contact Relation*

Medical History

Primary Physician & Address*

Phone*

Allergies

Has the student been tested for any of the following?*

Speech

Hearing

ADHD

Other

Has the student ever been diagnosed with any mental health disorder?*

yes

no

If yes, please specify here

I give consent for my child to be photographed and/or recorded during tutoring sessions and related activities for use in social media, marketing, and promotional materials by LightHouse Learning.*

Yes I consent

No I do not consent

Signature*

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