Applicant information

First name

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Last name

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Phone

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Phone type
Email address

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Email type
A.

General Information

Child's First Name:

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Child's Last Name:

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Date of Birth:

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Age (Note: Little Light House serves children 0-6 years of age):

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Description

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Weight:

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Height:

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Sex:

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B.

Parent/Guardian Information - Father

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Father's First Name:

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Father's Last Name:

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Father's Mailing Address (Line 1):

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Line 2:

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City:

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State:

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Zip Code:

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Father's Email:

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Father's Home Phone:

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Father's Work Phone:

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Legal Guardian (Father)

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C.

Parent/Guardian Information -Mother

If specified above, please mark these fields as N/A

Mother's First Name:

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Mother's Last Name:

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Mother's Mailing Address (Line 1):

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Line 2:

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City:

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State:

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Zip Code:

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Mother's Email:

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Mother's Home Phone:

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Mother's Work Phone:

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Legal Guardian (Mother):

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D.

Contact Confirmation

I understand that it is my responsibility to contact Little Light House, Inc., 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.

I Understand

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E.

Current Services

Please explain why your child is in need of special education and therapy services.

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Have you pursued services through First Steps?

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Have you pursued services through public schools?

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Are you aware of alternative programs for your child?

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Are you considering alternative programs until your child can be enrolled in Little Light House?

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F.

​What services (speech, physical, occupational therapy and/or special classes) is your child presently receiving?

Agency or School:

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Services:

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Primary Emphasis:

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For How Long?

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Agency or School:

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Services:

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Primary Emphasis:

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For How Long?

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Agency or School:

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Services:

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Primary Emphasis:

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For How Long?

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Who referred you to Little Light House?

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G.

Child Information

What is your child's diagnosis?

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What is/are your child's impairment(s) or delay(s) at this time?

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Please list the types of toys your child enjoys (music, switch toys, See'N Say, etc.):

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Please list the types of food your child eats and its consistency (tube feedings, baby food, pureed, chopped, finger foods, table foods):

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Does your child use a spoon independently?

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Does your child eat finger foods independently?

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Does your child drink from:

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How does your child let you know what he/she wants? (i.e., crying, pointing, etc.):

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What is your child's primary means of mobility?

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Please list any special equipment used with your child:

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Please list any special precautions that need to be taken with your child:

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Please list all medications and methods of administration:

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Please list all surgeries your child has had (i.e., tubes in ears, orthopedic, shunt, feeding tube, etc.)

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Please check applicable medical appliances and/or treatments:

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If your child has a prosthetic, please describe:

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If your child's appliance or treatment was not listed, please describe:

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Is there anything else you would like the Little Light House to know about your child?

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H.

Waiting List Testing Authorization

The undersigned, being the parent/legal guardian of the aforementioned child, does hereby authorize qualified staff of Little Light House, Inc. to administer psycho-educational, developmental, speech and language, and other types of diagnostic testing, as necessary for educational planning and 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. It is further understood that by clicking the "submit" button below, I (we) are giving our full consent.

I Understand

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Confirmation

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