Application for Children's Services Step 1 of 4 25% Today's date* MM slash DD slash YYYY Name of Child* First Middle Last Please attach a photo (snapshot) of childMax. file size: 300 MB.Child's Date of Birth*Little Light House serves children aged 0-6yo Month Day Year Child's Current Age*Little Light House serves children aged 0-6yo Gender* Male Female Height* Weight* Address of Residence* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code If the child is in foster care, please list the child's caseworkers name, phone, and email below.Child's Caseworkers NameChild's Caseworkers Phone NumberChild's Caseworkers Email Parent/Guardian InformationMarital Status* Single Married Divorced Other Guardian 1 (Mother's Name)* First Middle Last Mailing Address- If different than child's mailing address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Legal Guardian* Yes No Email* Enter Email Confirm Email Home PhoneCell Phone*Occupation* Workplace* Guardian 2 (Father's Name) First Middle Last Mailing Address- If different than child's mailing address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Legal Guardian Yes No Email Enter Email Confirm Email Home PhoneCell PhoneOccupation Workplace Who referred you to The Little Light House?* Current ServicesDoes your child have a diagnosis? Or suspected delay? If so, please list below.*What are your child's impairment(s) or delay(s) at this time?*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 through their DD3 and DD4 classes)?* Yes No Please list ALL surgeries your child has had (ear tubes, orthopedic, shunt, feeding tube, etc) (write NA if not applicable)*Is there anything else that you would like The Little Light House to know about your child (medical appliances, medications, feeding instructions, special precautions or equipment? Communication ChangesI 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. Communication changes: Initial Here* Tour requirementI understand that it is my responsibility to contact LLH to schedule and complete a tour within 30 days to be eligible for waiting list placement for my child. Should I fail to do this, I understand that my child could be withdrawn from the waiting list, due to not completing the requirements to join said waiting list. If my child is removed from the waiting list, I will have to restart the process to join the waiting list again. I will do my part to ensure that I fill all the requirements to join the Little Light House waiting list. 30 days to complete tour acknowledgement: Initial Here* LLH texting system authorizations*Opting into LLH texting system allows us to text the phone numbers provided about upcoming events, special requests, and urgent matters. I want to opt-in to the LLH texting system I do not want to opt-in to LLH texting system Texting system authorization: Initial Here* Early Intervention ProgramE.I. is a once-a-week program where the caregiver stays with their child in a two-hour class. This program empowers families to enhance their child's development through everyday activities that help them grow one inch at a time. I am interested in pursing the Early Intervention class, please send me more details via email. I am not interested in pursuing the Early Intervention program at this time. Family ProgramsFamily Programs are purpose-driven gatherings focused on education, therapy, and respite. It takes a village to raise a child. It takes a special village to raise a child who has a disability. We, at the Little Light House, want to be part of your family's village. Come and join us for weekly and monthly programs offered to empower, equip, and support families. I am interested in learning more about your Family Program, please send me more details via email. I am not interested in pursuing Family Programs at this time. Testing AuthorizationI, 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.Date* MM slash DD slash YYYY Legal Guardian Signature*
