25/26 The Lighthouse Preschool at Hartselle Church of Christ Registration

The Lighthouse Preschool at Hartselle Church of Christ Registration

August 2025-May 2026
Prior to filling out this form, please note that all students enrolled at The Lighthouse of Hartselle Church of Christ are required to submit an up to date vaccination record. At this time, we do not accept any exemptions.
I understand.
Student Information
Full Name (First, Middle, Last)
Name child goes by:
Date of Birth
Age of your child on 8/31/25: (Your child MUST be 1 on this date to enter into the program.)
Gender

MaleFemale
Home Address (Please do not leave this blank.)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number
Please enter a valid phone number.
Child lives with

Both ParentsDadMomOther
If Other, please list name and relationship.
Medical or Developmental Issues (allergies, hearing, eyesight, behavior, attention deficit, etc.) (write N/A if none) PLEASE NOTE THAT WE DO NOT HAVE MEDICAL PERSONNEL ON STAFF. WE DO NOT ADMINISTER MEDICATION OF ANY KIND. WE ARE ALSO NOT AN EARLY INTERVENTION SCHOOL. IF YOU NEED RESOURCES, WE ARE HAPPY TO ASSIST YOU.)
Fears, Worries or Dislikes (write N/A if none)
Mother/Guardian Information
Name
Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer/Occupation
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
example@example.com
Father/Guardian2 Information
Name
Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer/Occupation
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
example@example.com
Authorizations & Releases
Emergency Contact Information and phone number: * In the absence of parents, child can be released to: (Please list at least 2)
List up to 3 contacts other than parents (Name, Relationship to Child and Phone Number)
Child Pick up Authorization: * other than Parents & Emergency Contacts
Is there a court order preventing anyone from picking up your child? (If a court order exists, The Lighthouse Preschool will need to be provided with a copy to keep on file.)

YesNo
Is there anyone (non-court ordered) we should NOT release your child to? Please type their name and a brief description of them below.
Authorization to seek medical and dental treatment: Should an emergency arise, I authorize The Lighthouse Preschool to seek medical and/or dental care for my child at the nearest medical facility. I understand that I am responsible for any financial expenses that may incur.
Child's Physician
Name and Phone Number
Child's Dentist
Name and Phone Number
I agree that The Lighthouse in association with Hartselle Church of Christ along with any staff or employees shall be free and harmless of any claims, demands, or suits arising from the giving of consent for medical treatment of my child or children given by licensed medical providers and/or transportation of my child/children during such an emergency whether by the school’s staff, employees, or emergency vehicles/technicians.

I understand.
The Lighthouse has permission to photograph my child for newspaper articles, emails, texts, slide shows, groupme, facebook and to decorate our classrooms and/or hallway.

YesNo
I understand that The Lighthouse is not regulated by the Department of Human Resources.

I understand.
Please print your name below as a signature:

First NameLast Name
Class information:

Our program is designed for children one through five years old. Your child should be 1, 2, 3 or 4 years old by August 31, 2025 in order to enroll at subsequent levels. Children entering our 3-5 year-old classes should be potty-trained. All classes meet from 8:30am until 12:30pm on Monday's through Thursday's. You may choose to send your child for 4 days (Full time) or 2 to 3 days (part time). Part time is $180/month (2 days) or $210/month (3 days) or $235/month for Full time (4 days). All options require an $80 non refundable enrollment fee upon enrollment PER child. Once you receive an email stating that your child has been accepted into the program, your enrollment fee will need to be paid within 24 hours to hold their spot. Otherwise, it will then go to the next in line.
Please choose one:

Part time (Two Days Only)Part Time (Three Days Only)Full Time (Monday through Thursday)
Please list the days that you prefer if you selected "part time" as an option. PLEASE NOTE that our Tuesday and Thursday classes are almost full and we will begin placing kids where there is availability. Let us know below if there is a day that you just absolutely cannot make work. Thank you for understanding.
Should be Empty:

The Lighthouse Preschool at Hartselle Church of Christ Registration

Student Information

Mother/Guardian Information

Father/Guardian2 Information

Authorizations & Releases

Authorization to seek medical and dental treatment: Should an emergency arise, I authorize The Lighthouse Preschool to seek medical and/or dental care for my child at the nearest medical facility. I understand that I am responsible for any financial expenses that may incur.

Class information: