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, Grand Prairie TX

Grand Prairie

972-988-3900

GrandPrairie@ChildrensLighthouse.com
4636 Hwy 360 South
Grand Prairie, TX 75052

Grand Prairie, 4636 Hwy 360 South, Grand Prairie, TX 75052

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