Pre-Enrollment

Child’s Information:

Child’s Name

Date of Birth // Gender M F

Home Address

City State Zip Code

Home Phone

Mother’s Information

Mother’s Name

Employer Daytime Telephone

Cell Phone Number Email Address

Father’s Information

Father’s Name

Employer Daytime Telephone

Cell Phone Number Email Address

Enrollment:

Anticipated Enrollment Date //

I certify that the information given in this document is correct to the best of my knowledge. I am aware that I must pay a non-refundable registration fee by check or money order in order to secure my child’s spot. Submission of this document does not guarantee placement in the program.

Childrens Lighthouse, Lake Park NC

Lake Park

(704) 882-1100

director@childrenslighthousenc2.com
3309 Faith Church Road
Indian Trail, NC 28079

Lake Park, 3309 Faith Church Road, Indian Trail, NC 28079

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