Summer Camp Enrollment Form

2026 ENROLLMENT FORM

Please fill out the form for each summer camp candidate. Camp is open for children ages 5-12. Deadline June 15th, 2026.
Date

MonthDayYear
Date
Name of person enrolling child

First NameLast Name
Relationship to child
Primary contact number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency contact name

First NameLast Name
Emergency contact phone number
Please enter a valid phone number.Format: (000) 000-0000.
Other adult allowed to pick up child

First NameLast Name
Have you previously attended the Lighthouse?

YesNo
T-Shirt Size

Youth SmallYouth MediumYouth LargeYouth X-LargeOther
1st Child's Information
Child's name

First NameLast Name
Birthday (must be 5 yrs. by start of camp)

MonthDayYear
Date
Grade
Please Select

MaleFemale
Type of Loss

Death of MotherDeath of FatherDeath of SiblingDivorce/SeparationIncarcerationAbandonmentOther
How long since the loss?
Is the child experiencing difficulties with any of the following:

SleepingGradesCommunicationEating habitsSubstance abusePeer relationsSchool attendanceAttitudeBehaviorSuicidalSelf esteemOther
Please list any medications/allergies
Ethnicity
This information is used for grant funding purposes.
Income
This information is used for grant funding purposes.
2nd Child's Information
Child's name

First NameLast Name
Birthday (must be 5 yrs. by start of camp)

MonthDayYear
Date
Grade
Please Select

MaleFemale
Type of Loss

Death of MotherDeath of FatherDeath of SiblingDivorce/SeparationIncarcerationAbandonmentOther
How long since the loss
Is the child experiencing difficulties with any of the following:

SleepingGradesCommunicationEating habitsSubstance abusePeer relationsSchool attendanceAttitudeBehaviorSuicidalSelf esteemOther
Please list any medications/allergies
Ethnicity
This information is used for grant funding purposes.
Income
This information is used for grant funding purposes.
3rd Child's Information
Child's name

First NameLast Name
Birthday (must be 5 yrs. by start of camp)

MonthDayYear
Date
Grade
Please Select

MaleFemale
Type of Loss

Death of MotherDeath of FatherDeath of SiblingDivorce/SeparationIncarcerationAbandonmentOther
How long since the loss
Is the child experiencing difficulties with any of the following:

SleepingGradesCommunicationEating habitsSubstance abusePeer relationsSchool attendanceAttitudeBehaviorSuicidalSelf esteemOther
Please list any medications/allergies
Ethnicity
This information is used for grant funding purposes.
Income
This information is used for grant funding purposes.
4th Child's name

First NameLast Name
Birthday (must be 5 yrs. by start of camp)

MonthDayYear
Date
Grade
Please Select

MaleFemale
Type of Loss

Death of MotherDeath of FatherDeath of SiblingDivorce/SeparationIncarcerationAbandonmentOther
How long since the loss
Is the child experiencing difficulties with any of the following:

SleepingGradesCommunicationEating habitsSubstance abusePeer relationsSchool attendanceAttitudeBehaviorSuicidalSelf esteemOther
Please list any medications/allergies
Ethnicity
This information is used for grant funding purposes.
Income
This information is used for grant funding purposes.
Date Received
Constant Contact
Realm
EZ Texting
Dates contacted
Notes
Type a question
Signature
Should be Empty:

2026 ENROLLMENT FORM

1st Child's Information

2nd Child's Information

3rd Child's Information