Application for Children's Services Are you the Child's Legal Guardian?(Required) Yes No Only a legal guardian may fill out the form. A legal guardian is someone who has the legal authority and responsibility to care for a child and make important decisions on their behalf. A legal guardian is typically: A parent (biological or adoptive). A court-appointed guardian (someone officially designated by a judge to care for the child). Someone with legal custody (such as a relative or foster parent, depending on the situation).Child's Current Age(Required)Little Light House serves children aged 0-6yoHere is a list of recourses provide in Oklahoma that may be able to help you: View Resource List Child's Date of Birth(Required)Little Light House serves children aged 0-6yo Month Day Year Which location are you enrolling for?(Required) Tulsa Oklahoma City Both Due to the length of our Tulsa location waitlist, we recommend that you enroll in our Family Learning Center at the Tulsa location. Our OKC location does not currently have an FLC program.Due to the length of our Tulsa location waitlist, we recommend that you enroll in our Family Learning Center at the Tulsa location. Our OKC location does not currently have an FLC program.Which program are you interested in joining? (You can choose both)(Required)We have two programs to serve your child. The Developmental Center classes are our full time classes Monday - Thursday. Our Family Learning Center classes are a once a week two our class that a parent or caregiver attends with their child. Developmental Center (DC) Family Learning Center (FLC) Both Which program are you interested in joining? (You can choose both)(Required)We have two programs to serve your child. The Developmental Center classes are our full time classes Monday - Thursday. Our Family Learning Center classes are a once a week two our class that a parent or caregiver attends with their child and is ONLY PROVIDED AT OUR TULSA LOCATION. Developmental Center (DC) Family Learning Center (FLC) Tulsa Only Both Which program are you interested in joining?(Required)Developmental Center is currently the only program provided by our OKC location. Developmental Center (DC) Today's date(Required) MM slash DD slash YYYY Child InformationName of Child(Required) First Middle Last Gender(Required) Male Female Please select your child’s diagnosed condition(s). Check all that apply.Note: A diagnosis is not required for services. If your child has a genetic disorder or other delays, you may include that in the “Other” section. Autism Spectrum Disorder (ASD) Down Syndrome Cerebral Palsy Visual Impairment / Blind Hearing Impairment / Deaf Agenesis of Corpus Collosum Spina Bifida Sensory Processing Disorder Epilepsy / Seizure Disorder Developmental Delay ADHD Microcephaly Hydrocephaly Lissencephaly Congenital Heart Defect Other Not yet diagnosed If other, please fill out here.Is your child Native American?Your responses are optional and will not affect your child’s eligibility or enrollment at Little Light House. This information is collected solely to help us meet reporting requirements for grants and funding sources that support our programs. Yes No Prefer not to answer What is your child's race/ethnicity?Your responses are optional and will not affect your child’s eligibility or enrollment at Little Light House. This information is collected solely to help us meet reporting requirements for grants and funding sources that support our programs. Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Other Prefer not to answer If other, please fill out here.Primary Language Spoken at Home(Required) English Spanish Other Address of Residence(Required) 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 Parent/Guardian InformationGuardian 1(Required) First Middle Last Check if Mailing Address is the same as the Child's Address is the same 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 Check all that apply Legal Guardian Lives in home with enrolling child Can contact them regarding child's enrollment Email(Required) Enter Email Confirm Email Home PhoneGuardian 2 First Middle Last Check all that apply Legal Guardian Lives in home with enrolling child Can contact them regarding child's enrollment Email Enter Email Confirm Email Cell PhoneHow did you hear about Little Light House?(Required) Social Media (Facebook, Instagram, etc.) Website/Search Engine Friend or Family Referral Event or Community Outreach Doctor or Therapist Referral Other Waitlist Communication RequirementsOnce a year, you will get an email from our Outreach Coordinator with your child's waitlist RANGE. We do NOT give individual waitlist numbers. When you receive this annual email, we require that you communicate with us to let us know you are still interested in remaining on our waitlist and updating your contact information. If we do not receive communication from you at that time, we will begin our "Lost Contact" procedure. After 3 failed attempts to reach you, your child will be removed from the waitlist. Please add waitlist@littlelighthouse.org to your email contacts so that you never miss an email from us! I understand that it is my responsibility to contact Little Light House, in writing of change concerning any component that could deter communications between 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 Little Light House to contact me. I will do my part to ensure that Little Light House is able to communicate with me at all times. Waitlist Communication Requirements Initial Here(Required)Cell Phone(Required)LLH texting system authorizations(Required)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(Required)CommentsThis field is for validation purposes and should be left unchanged.
