Lighthouse Church School Registration Form

Welcome to Lighthouse Church School!

We are excited to have you as part of our school community. Our mission is to cultivate transformation by equipping students with knowledge, strengthening their faith, and empowering them to share the Word of God.

Annual Requirements for All Students:

Registration Form
Annual Health Physical
Registration Payment

Additional Requirements for New Students Only:

Copy of Birth Certificate
Copy of Immunization Record
Oral Health Assessment Form
Mandatory Assessment Test – $100 fee (non-refundable)

We look forward to a blessed and enriching school year with you!

Academic Year:

STUDENT INFORMATION

Student Name:

Date of Birth:

1

Gender:

Male‎ Female‎

Applying to Enter Grade:

Date of Application:

Home Address:

City:

State:

Zip Code:

PARENT/GUARDIAN INFORMATION

Father/Guardian Name:

Occupation or Name of Employer:

Cell Phone:

Email:

Home Address (if different from student’s):

Mother/Guardian Name:

Occupation or Name of Employer:

Cell Phone:

Email:

Home Address (if different from student’s):

1

Parent's Marital Status:

Married‎ Divorced‎ Other‎

Other Marital Status:

With whom does the student reside?:
Father and/or Mother - Guardian name - other

1

To whom should correspondence be sent?

Father‎ Mother‎ Both‎

Emergency Contact Information

Provide at least one additional contact in case of emergency

Name

Phone

Email

RELEASE AUTHORIZATION

The undersigned legal guardian(s) of the above-named student do hereby authorize and consent to the release by The Lighthouse Church School of said student to the following persons: (List full name for each person. A call is not sufficient for the school to release a child to someone other than the named individuals below. You must send a written note.)

The following people are authorized to pick up your child:
Name - Relationship - Phone number

Medical Information

Does your child have any known food or drug allergies?

No Yes

If yes, please explain:

Acceptance:
If your child has allergies, you are required to provide EpiPens as needed—one for the classroom and one for the office.

I acknowledge and agree to this requirement.

Does the student have any medical conditions the school should be aware of?

No Yes

If yes, please explain:

Does the student take any medications during school hours?

No Yes

If yes, please explain:

Insurance Company Name:

Policy Number:

Physician's Name:

Physician's Phone Number:

TUITION AGREEMENT

Registration Fee ($650): Annual and non-refundable.

Tuition: $650 (K-5th), $700 (Middle School)

Tuition Payment Options (please choose one of the following payment plans):

Full Payment: Pay the entire tuition upfront. Four-Payment Plan: Divide the tuition into four equal payments Monthly Plan: Pay in 10 monthly installments, with payments due on the 1st of each month.

I hereby agree to pay Lighthouse Church School (Santa Monica Foursquare Church) the registration payment and annual tuition. I understand that failure to fulfill outstanding tuition or fees may result in additional penalties, withholding of records, and/or separation from the school.

This tuition payment is for the education of my student. I understand that in the event I decide to withdraw my student from the school, I must provide a 30-day notice to the school.

Acceptance:

I have read and agree to "Tuition Agreement".

Fundraiser Participation Agreement

I agree to participate in the mandatory fundraisers organized by Lighthouse Church School. There are three required fundraisers each year. If I choose not to participate, I agree to pay an exemption fee of $100 per fundraiser ($300 total). I acknowledge that failure to make these payments may lead to the possibility of my child's expulsion from the school.

Acceptance:

I have read and agree to "Fundraiser Participation Agreement".

STUDENT HANDBOOK AGREEMENT

I have read and understand the school handbook and agree to follow all policies and procedures outlined within. I understand that failure to comply with school policies may result in disciplinary action, including expulsion.

Copy of Acceptance:

I have read and agree to "STUDENT HANDBOOK AGREEMENT"

AUTHORIZATION TO TREAT A MINOR

I/We, the undersigned parent(s) or legal guardian(s) of a minor, authorize The Lighthouse Church School to arrange emergency medical, surgical, or dental care if I/we am unavailable. I/We permit any licensed physician or dentist at an accredited hospital to administer necessary treatment, including X-rays and anesthesia. While efforts will be made to contact me/us first, treatment will not be withheld if I/we cannot be reached. I/We accept full financial responsibility for any medical treatment authorized by the school and for any injuries my child may sustain on or off school premises. I/We confirm that my child is cleared for physical education and school sports unless a physician provides written restrictions. Any medical excuse must be submitted to the school with details on the duration of limitations. I/We will inform the school of any allergies or required medications before the first day of attendance or upon return. I accept full financial responsibility for any medical costs incurred.

Acceptance:

I have read and agree to "Authorization to Treat a Minor"

Release of Liability:

I/We, the undersigned parent(s) or legal guardian(s), understand and acknowledge the risks associated with my child’s participation in school activities, including but not limited to physical education, field trips, and extracurricular programs. I/We assume full responsibility for any injuries, damages, or losses that may occur. I/We release The Lighthouse Church School, Santa Monica Foursquare Church, its employees, volunteers, and affiliates from any claims, liabilities, or expenses arising from my child’s participation in school activities. I/We understand that once my child leaves school premises, including after-school activities and field trips, I/we assume full responsibility for their safety. I/We certify that all provided information is accurate and that no details have been withheld or misrepresented. I/We acknowledge that any falsification or omission may result in my child's dismissal from the school. I/we confirm that my child is a suitable and safe companion for peers, teachers, and staff and does not pose any known risk to the well-being of others.

Acceptance:

I understand that checking this circle constitutes a legal signature confirming that I acknowledge and agree to the above terms.

Parent/Guardian Electronic Signature:

Date:

Parent/Guardian Electronic Signature:

Date:

For New Students Only

(Returning students do not need to complete this section.)

Additional Information

Primary Language Spoken at Home

Country of Birth

Citizenship

Has the student previously attended any school?

Yes‎ No‎

If yes, please provide the previous school name, school address, and the last grade completed:

List siblings (name- age- grade- current school)

Educational Background

Has the student received any special education services?

Yes No

If yes, please specify

Has the student participated in any gifted or advanced programs?

Yes No

If yes, please specify

Does the student require English as a Second Language (ESL) support?

Yes No

If yes, please specify

You already reached the maximum number of accepted choices