CHILD SUPPORT GROUP ENROLLMENT
Please fill out the form for each person under the age of 18.
Date
-
Month
-
Day
Year
Date
Name of person enrolling child
First Name
Last Name
Relationship to child
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency contact name
First Name
Last Name
Emergency contact phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Have you previously attended the Lighthouse?
Yes
No
Child's Information
Child's name
First Name
Last Name
Birthday
-
Month
-
Day
Year
Date
Grade
Type a question
Male
Female
Type of Loss
Death of Mother
Death of Father
Death of Sibling
Divorce/Separation
Incarceration
Abandonment
Other
How long since the loss
Is the child experiencing difficulties with any of the following:
Sleeping
Grades
Communication
Eating habits
Substance abuse
Peer relations
School attendance
Attitude
Behavior
Suicidal
Self esteem
Other
Please list any medications
Other adults attending with child
First Name
Last Name
Back
Next
Date Received
Constant Contact
Realm
EZ Texting
Dates contacted
Notes
Submit
Should be Empty: