Lighthouse Out-of-School Time Program

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In-Take Form: Child and Parent Information

The Lighthouse After School Program will be hosting Virtual activities for Middle and High School kids until June 30th 2020. Some of the programing will be on our Facebook Page and our YouTube Channel. 
Child's Grade *
Child's Actual Age *
Relationship to Child *

Child's Personal Information

Child's Race: Check all that apply *
Child's Special Needs: Check all that apply *

School Information

MEANS Test Worksheet

Is the Child MALE or FEMALE *
1. Is the Child/Family receiving...: Check all that apply *
2. Is the Child a U.S. Citizen or qualified alien? *
In order to be eligible for services and Child/family's income must meet one of the options listed below. Please select the option that fits you best. *
4. Is the Child under the age of 18? *
5. Is the Child living in the home of a parent, other adult specified relative or a court designated legal custodian? *
6. Is the Child/family receiving assistance from TANF, SSI, Food Stamps, MEDICAID? And Questions 4 and 5 are YES or answers 2,3,4 and 5 are all YES, the child may be eligible for TANF funding for services pending income information: *

MEANS Test Worksheet Continued: Mother/Legal Guardian

MEANS Test Worksheet Continued: Father/Legal Guardian