Application for Children's Services

Communication Changes
I understand that it is my responsibility to contact The Little Light House, Inc., in writing of change concerning any component that could deter communications between The Little Light House, myself, and said child. This includes but is not limited to a change of telephone number, name, and/or address. Should I fail to do this, I understand that my child could be withdrawn from the waiting list, due to the inability of The Little Light House to contact me. I will do my part to ensure that The Little Light House is able to communicate with me at all times.
Initial Here*
Communication Consent
Parent Ambassadors are parents of active LLH Developmental Center students who volunteer to support new families in their journey with LLH. Parent Ambassadors have been screened trained and mentored by LLH personnel and are well versed in the needs of special needs families. Initial one of the following to indicate your choice:
Initial Here*
Consent*
- I give my consent for a Little Light House Parent Ambassador to contact me via my preferred form of communication to provide additional support and information.
- I do not give my consent for a Little Light House Parent Ambassador to contact me
Initial Here*

Current Services
Please explain why your child is in need of special education and therapy services:*
Have you pursued early intervention services through the state (ex: Sooner Start)?*
- Yes
- No
Have you pursued services through public schools (services available at age 3yo)?*
- Yes
- No
Are you aware of any alternative programs for your child?*
- Yes
- No
Are you considering an alternative program until your child can be enrolled in The Little Light House?*
- Yes
- No

What services (speech, physical, occupational therapy and/or special classes) is your child presently receiving?
Service #1
Agency/School
For how long?
Services
Primary Emphasis
Service #2
Agency/School
For how long?
Services
Primary Emphasis
Service #3
Agency/School
For how long?
Services
Primary Emphasis
Who referred you to The Little Light House?

Testing Authorization
I, being the parent/legal guardian of the child for which this application is submitted, do hereby authorize qualified staff of The Little Light House, Inc. to administer psycho-educational, developmental and other types of screening testing, as necessary for placement purposes. It is understood that the said results will be considered confidential and will be released to other agencies only by the signed authorization of the parents or legal guardian of the child.
Parent/Legal Guardian Signature*
Date*
MM slash DD slash YYYY

Parent/Guardian Information