Lighthouse Kids Registration Form
2025-2026 School Year
Student Information
*
Frist Name
Last Name
Date of Birth
*
Current Age
*
Grade
*
Parent/Guardian Information
*
First Name
Last Name
Relationship to student
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to student
*
Persons Allowed to Pick Up
Name
*
Phone Number
*
Name
*
Phone Number
*
If your child has special accommodations or allergies, please specify here.
*
Do you grant permission for Lighthouse Church to use your child's picture on our website and/or social media?
*
Please type yes or no.
Signature
*
Date
*
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: