Early Childhood Application 2024-2025

Cameron Parish Coordinated Enrollment Application-Early Childhood

Please indicate your Early Childhood Provider Preference*

Answer Required

Cameron Parish School System - Grand Lake Elementary - Pre-K

Cameron Parish School System - Hackberry High School - Pre-K

Cameron Parish School System - Johnson Bayou High School - Pre-K

Cameron Parish School System - South Cameron High School - Pre-K

Cameron Parish Head Start - Grand Lake

Cameron Parish Head Start - Hackberry

South Cameron Early Learning Center

STUDENT INFORMATION

Last Name*

Answer Required

First Name*

Answer Required

Middle Name*

Answer Required

Gender*

Answer Required

Male

Female

Date of Birth*

Answer Required

Place of Birth*

Answer Required

SSN

Answer Required

Mother's Maiden Name*

Answer Required

Race of Child: (check all that apply)*

Answer Required

White

Black

Native Am/Alaskan

Hawaiian/Pacific Islander

Hispanic

Asian

First language spoken by student*

Answer Required

Languages spoken at home*

Answer Required

Street Address*

Answer Required

City*

Answer Required

Zip/Postal*

Answer Required

Parent/Guardian 1 Info

First Name*

Answer Required

Last Name*

Answer Required

Address Same as Student

Answer Required

Yes

Street Address

Answer Required

City

Answer Required

State

Answer Required

Zip/Postal Code

Answer Required

Email Address*

Answer Required

Mobile Phone*

000-000-0000

Number Required

Work Phone

000-000-0000

Number Required

Relation to Child:*

Answer Required

Employer*

Answer Required

Parent/Guardian 2 Info

First Name*

Answer Required

Last Name*

Answer Required

Address Same as Student

Answer Required

Yes

Street Address

Answer Required

City

Answer Required

State

Answer Required

Zip/Postal Code

Answer Required

Email*

Answer Required

Mobile Phone*

000-000-0000

Number Required

Work Phone

000-000-0000

Number Required

Relation to Child:*

Answer Required

PARENTAL STATUS OF MOTHER AND FATHER*

Answer Required

Single

Married

Separated

Divorced

Emergency Contact Info

Contact #1 Name - First & Last*

Answer Required

Relationship to student*

Answer Required

Email 1

Answer Required

Phone 1*

000-000-0000

Number Required

Phone 2

000-000-0000

Number Required

Contact #2 Name - First & Last*

Answer Required

Relationship to student*

Answer Required

Email 1

Answer Required

Phone 1*

000-000-0000

Number Required

Phone 2

000-000-0000

Number Required

Family Size: The family size is to be determined by including all persons living in the household who are supported by the income of the child's parents or guardians and related to the parents or guardians by blood, marriage, or adoption.

Family Size*

Answer Required

Total Adults*

Answer Required

Number of Children*

Answer Required

Ages of Children*

Answer Required

Are you and your family:

Answer Required

Foster Family

Homeless

Do you receive: (please check all that apply)

Answer Required

SSI

FITAP/TANF

SNAP

WIC

N/A

Is your child covered by medical insurance? If yes, provide name.*

Answer Required

Is your family covered by medical insurance? If yes, provide name. *

Answer Required

Medical Issues

Does child have any know food or medication allergies? If yes, please identify:*

Answer Required

Does child have a diagnosed medical or psychological condition, including congenital birth defects or a physical disability? If yes, please identify:*

Answer Required

Please furnish written documentation from a qualified medical professional for any issues listed above to the school counselor.

Does your child have a current:*

Answer Required

IEP

IAP

ISFP

Other concerns:

Answer Required

Family Doctor Name and Phone Number*

Answer Required

Dentist Name and Phone Number

Answer Required

Enrollment Documentation Required:

1. Birth Certificate

2. Up-to-date Immunization Record

3. IEP or Early Steps Documentation (if applicable)

4. Diagnosed Medical or Psychological Condition (if applicable)

5. Certified Court Orders of Legal Documentation of Guardianship (if applicable)

Upload Enrollment Documentation Here

Answer Required

Choose a file or drag it here.

Proof Residency Required - (minimum of 2 documents)

-Louisiana driver's license w/current address

-Voter Registration Card w/current address

-Current Property Tax Statement showing homestead exemption

-Utility Bill showing account holder's name and service address (electricity and/or gas)

-Current lease or mortgage statement

Upload TWO Residency Documents Here

Answer Required

Choose a file or drag it here.

Proof of Income for BOTH parents is required. Please check proof of income that applies below.*

Answer Required

Two (2) consecutive check stubs for the current year (within 2 months from the date of completing this application).

State of No Income form --for parents/guardians who claim zero income of any kind. (Form can be found on website - complete form and upload here)

Declaration of Income for Irregular Employment form --for parents/guardians who are employed intermittently, self-employed, or who do not have tax forms, W-2 forms or check stubs. (Form can be found on website - complete form and upload here)

Upload Proof of Income for BOTH Parents Here

Answer Required

Choose a file or drag it here.

Previous School Information

Name of School & School Phone Number

Answer Required

Please list any concerns and/or comments below:

Answer Required

My INITIALS below certify that all enrollment information provided today is current and accurate. I understand that if any of the above information is not submitted or proves to be inaccurate, the child may be subject to exclusion from the Cameron Parish Early Childhood System.*

Add initials below

Answer Required

Date*

ex. 01/05/2022

Answer Required

Please fix the highlighted areas below before submitting.

Early Childhood Application 2024-2025