Lighthouse Church of God – Before & After School Program Application

The Lighthouse Before & After School Program provides safe, engaging, and affordable childcare for students in grades K–6. Our program offers a nurturing environment where children can receive homework help, participate in fun activities, and build positive relationships.

Whether your child needs care before school, after school, or both, our trained staff is committed to supporting their growth, creativity, and well-being. We partner with parents to ensure every child’s needs are met while providing peace of mind during working hours.

Complete all sections of this application form. Incomplete applications may delay enrollment.
One application per child is required.

Section 1 – Student Information

First name

Last name

Birthday

Month

Day

Year

Grade Level (K–6)

School Currently Attending

Home Address

Primary Language Spoken at Home

Section 2 – Parent/Guardian Information

Parent/Guardian Name(s)

Relationship to Child

Home Phone Number

Cell Phone Number

Email Address

Employer Name & Work Phone Number

Secondary Contact (if applicable)

Section 3 – Emergency Contacts (Other Than Parent/Guardian)

Full Name

Relationship to Child

Phone Number(s)

Authorized to Pick Up? (Yes/No)

Section 4 – Pick-Up Authorization

List all individuals authorized to pick up your child (full name, relationship, phone number). Photo ID will be required.

Section 5 – Program Schedule

Will your child attend: Which days will your child attend? (Check all that apply: Mon / Tue / Wed / Thu / Fri)

Monday

Tuesday

Wednesday

Thursday

Friday

Approximate Drop-Off Time:

Time

HoursMinutes

Approximate Pick-Up Time:

Section 6 – Medical & Safety Information

Allergies (food, medication, environmental) — list specifics and reactions

Special dietary needs

Medical conditions or chronic illnesses (e.g., asthma, diabetes)

Medications taken regularly (name, dosage, schedule)

Any activity restrictions

Physician’s Name & Phone Number

Preferred Hospital

Insurance Provider & Policy Number

Section 7 – Special Needs or Additional Support

Does your child have an IEP, 504 Plan, or receive special education services? (Yes/No — please explain)

Are there any behavioral or emotional needs we should be aware of?

Any other important notes about your child’s learning style, interests, or personality?

Section 8 – Permissions & Agreements

Photo/Video Permission: Do you give permission for your child to be photographed or recorded for program use/social media? (Yes/No)

Transportation Permission: If applicable, do you give permission for your child to ride in program-approved transportation? (Yes/No)

Emergency Medical Consent: Do you authorize emergency medical care if you cannot be reached? (Yes/No)

Policy Agreement: Do you agree to follow the program’s policies and payment schedule? (Yes/No)

Section 9 – Signature

Parent/Guardian Signature

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Date

Month

Day

Year

Choose a service

AM (before school only)$50

PM (after school only)$60

AM + PM (both sessions)$110