LIGHTHOUSE KINGDOM KIDS
                                               REGISTRATION FORM


CHILD'S FULL NAME_________________________________________________
NAME CHILD GOES BY__________________BIRTH DATE______________________
ADDRESS_______________________________________________________
AS OF AUG 15TH, 20__  MY CHILD WILL BE___YRS. AND _____ MO.
HOME PHONE_____________ ATTENDING CHURCH__________________________

PARENT INFORMATION:
MOTHER'S NAME____________________ FATHER'S NAME_________________
MOTHER'S                                            FATHER'S
ADDRESS__________________________ADDRESS_________________________

EMPLOYER_______________________ EMPLOYER_______________________
WORK#_________________________ WORK#__________________________
CELL#__________________________ CELL#__________________________

PEOPLE AUTHORIZED TO PICK UP YOUR CHILD:

NAME_________________________ RELATIONSHIP_______________________
NAME_________________________ RELATIONSHIP_______________________











MEDICAL INFORMATION
:

CHILD'S PHYSICIAN_________________________ PHONE#___________________
CHILD'S DENTIST__________________________ PHONE#___________________
PLEASE LIST ANY ALLERGIES__________________________________________
SYMPTOMS OF THOSE ALLERGIES_______________________________________
DOES YOUR CHILD TAKE ANY DAILY MEDICATIONS?____________________________
PLEASE LIST_____________________________________________________
PLEASE LIST ANY OTHER MEDICAL INFORMATION_____________________________
______________________________________________________________

EMERGENCY INFORMATION:

PERSON AUTHORIZED TO PICK UP YOUR CHILD IN THE CASE OF AN EMERGENCY:
(PLEASE LIST AT LEAST TWO NUMBERS)

NAME________________________ RELATIONSHIP________________________
NAME________________________ RELATIONSHIP________________________

WHAT IS YOUR HOPE FOR YOUR CHILD IN ATTENDING OUR PROGRAM?_______________
______________________________________________________________

CIRCLE ANY OF THE FOLLOWING MOTOR/ACADEMIC SKILLS IN WHICH YOUR CHILD HAS MASTERED:
RECOGNIZING LETTERS      RECOGNIZING NUMBERS        LETTER SOUNDS
TYING HIS/HER SHOES

RECOGNIZING COLORS/SHAPES      SKIPPING      JUMPING      BEGINNING TO READ

COUNTING FROM__TO___

WHAT IS HIS/HER FAVORITE COLOR?__________ HOBBY?____________________

LIST ANY OTHER INFORMATION THAT WOULD BE HELPFUL TO YOUR CHILD'S TEACHER__
_____________________________________________________________________________________________________________________________________________________________________________________________

DO YOU HAVE ANY SPECIAL SKILLS AND/OR HOBBIES IN WHICH YOU WOULD BE ABLE TO SHARE WITH STUDENTS?____________________________________________
_____________________________________________________________









ARE YOU WILLING TO VOLUNTEER FOR SPECIAL DAYS/EVENTS?_______________
________READ A BOOK
________HELP WITH HOLIDAY PARTIES
________HELP IN GYM TIME, IF SO HOW OFTEN__________________________
________HELP WITH FUNDRAISING
________ANY OTHER VOLUNTEER WORK_______________________________

WHAT IS THE BEST NUMBER TO REACH YOU? __________________________


BY SIGNING THIS DOCUMENT, I UNDERSTAND THE ABOVE INFORMATION TO BE TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. I HAVE READ AND UNDERSTOOD THE POLICIES OF THE KINGDOM KIDS PROGRAM AND AGREE TO COMPLY BY ITS POLICIES.


PARENT'S PRINTED NAME__________________________

PARENT'S SIGNATURE__________________________ DATE_______________