Little Lighthouse Registration
Email address *
Child's Name *
Your answer
Child's Date of Birth *
MM
/
DD
/
YYYY
I would like to register for the following session (please select one): *
Mother's Name *
Your answer
Mother's Cell *
Your answer
Mother's Email *
Your answer
Mother's Mailing Address *
Your answer
Father's Name *
Your answer
Father's Cell *
Your answer
Father's Email *
Your answer
Father's Mailing Address *
Your answer
How did your hear about us? *
Your answer
Household Language *
Required
A copy of your responses will be emailed to the address you provided.
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