Enrollment

Parent Information

Title

First Name

Middle Name

Last Name

Address Line 1

Address Line 2

City

State

Zip

Email Address

Phone

Student Information

Is your student currently suspended or expelled? (required) Yes No

Has your student had court involvement? Truancy, DHHS, Family Court, etc

First Name

Middle Name

Last Name

Date of Birth

Entering Grade Level

Name of school student attended previously

Address of school student attended previously

Phone of school student attended previously

Has the student received Special Education services before?

Type of Special Education services student received previously (if you checked the previous question)

Reason for interest in attending Lighthouse Academy

How did you learn about Lighthouse? If you were referred to the school, who referred you?

Do you have any questions?

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