• P.O. Box 238, Loranger, LA 70446

    Phone: (985) 878-6560 • Fax: (985) 878-9370
  • Admission Application

    Contact Information for Resident / Parent / Guardian
  •  /  /
    Pick a Date
  •  /  /
    Pick a Date
  •  /  /
    Pick a Date
  • In order to properly communicate, we need to have all contact information for the parent/guardian of the resident. We ask each parent/guardian to provide an email address so that we can keep you informed as well as provide you with updated documents, reportsandaccounting information.

  • Resident

  •  /  /
    Pick a Date
  • Parent or Guardian

  •  /  /
    Pick a Date
  • As applicable:

  • Admission Application

    Current Family Data
    • Biological Father  
    •  -  -
      Pick a Date
    •  -  -
      Pick a Date
    • Biological Mother  
    •  -  -
      Pick a Date
    •  -  -
      Pick a Date
    • Step / Foster Father  
    •  -  -
      Pick a Date
    •  -  -
      Pick a Date
    • Step / Foster Mother  
    •  -  -
      Pick a Date
    •  -  -
      Pick a Date
    • End  
    • Emergency Contacts (Provide at least 3 contacts)

    • Admission Application

      Family History
    • Family Involvement

      Please indicate your willingness to adhere to and/or participate as necessary:

    • Clear
    • Clear
    • Clear
    • Clear
    • Clear
    • Clear
    • I hereby request that the Lighthouse Ranch for Boys consider providing services to the above-named child. All information provided is accurate to the best of my knowledge. I understand that any deliberately false information is grounds for denial into the program.

    • Clear
    •  /  /
      Pick a Date
    • Clear
    •  /  /
      Pick a Date
    • Admission Application

      Medications Form
    • Current Prescribed Medications

    •  /  /
      Pick a Date
    • Clear
    •  /  /
      Pick a Date
    • Non-Prescription (Over the Counter) Medication List

    • Clear
    •  /  /
      Pick a Date
    • Admission Application

      History and Psychosocial Information
    • Education:

    • Social History:

    •  
    • Should be Empty:
Jotform Logo
Now create your own Jotform - It's free! Create your own Jotform