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, Hickory Creek TX

Hickory Creek

940-321-9232

HickoryCreek@ChildrensLighthouse.com
1001 Point Vista Road
Hickory Creek, TX 75065

Hickory Creek, 1001 Point Vista Road, Hickory Creek, TX 75065

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