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Pre-Application Assessment: Child and Parent Information

This is a pre-application assesment. A Lighthouse Team Member will contact you
with additiobnal guidance on completing the full application.
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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 *

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. *
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