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Early Childhood Education Application 2025-2026

Cameron Parish Coordinated Enrollment Application-Early Childhood

Please indicate your Early Childhood Provider Preference*

Answer required for "Please indicate your Early Childhood Provider Preference"

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

The Playground of Grand Lake, LLC.

STUDENT INFORMATION

Last Name*

Answer required for "Last Name"

First Name*

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Middle Name*

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Gender*

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Male

Female

Date of Birth*

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Place of Birth*

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SSN

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Mother's Maiden Name*

Answer required for "Mother's Maiden Name"

Race of Child: (check all that apply)*

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White

Black

Native Am/Alaskan

Hawaiian/Pacific Islander

Hispanic

Asian

First language spoken by student*

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Languages spoken at home*

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Street Address*

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City*

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State*

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Zip/Postal*

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Parent/Guardian 1 Info

First Name*

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Last Name*

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Address Same as Student

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Yes

Street Address

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City

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State

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Zip/Postal Code

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Email Address*

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Mobile Phone*

000-000-0000

Number Required

Work Phone

000-000-0000

Number Required

Relation to Child:*

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Employer*

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Does student live with this person?*

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Parent/Guardian 2 Info

First Name*

Answer required for "First Name"

Last Name*

Answer required for "Last Name"

Address Same as Student

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Yes

Street Address

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City

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State

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Zip/Postal Code

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Email*

Answer required for "Email"

Mobile Phone*

000-000-0000

Number Required

Work Phone

000-000-0000

Number Required

Relation to Child:*

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Does student live with this person*

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PARENTAL STATUS OF MOTHER AND FATHER*

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Single

Married

Separated

Divorced

Emergency Contact Info

Contact #1 Name - First & Last*

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Relationship to student*

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Email 1

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Phone 1*

000-000-0000

Number Required

Phone 2

000-000-0000

Number Required

Contact #1 has permission to sign out my child*

Answer required for "Contact #1 has permission to sign out my child"

Contact #2 Name - First & Last*

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Relationship to student*

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Email 1

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Phone 1*

000-000-0000

Number Required

Phone 2

000-000-0000

Number Required

Contact #2 has permission to checkout my child*

Answer required for "Contact #2 has permission to checkout my child"

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*

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Total Adults*

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Number of Children*

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Ages of Children*

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Are you and your family:

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Foster Family

Homeless

Do you receive: (please check all that apply)

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SSI

FITAP/TANF

SNAP

WIC

N/A

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

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

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Medical Issues

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

Answer required for "Does child have any know food or medication allergies? If yes, please identify:"

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

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

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

Does your child have a current:*

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IEP

IAP

ISFP

Other concerns:

Answer required for "Other concerns:"

Family Doctor Name and Phone Number*

Answer required for "Family Doctor Name and Phone Number"

Dentist Name and Phone Number

Answer required for "Dentist Name and Phone Number"

Enrollment Documentation Required:

1. Proof of Income

2. Birth Certificate

3. Up-to-date Immunization Record

4. Proof of Residency

5. IEP, Early Steps Documentation, Diagnosed Medical or Psychological Condition (if applicable)

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

The following link will open into a new window. This form MUST be completed to complete registration.

PreK Registration Developmental Questionnaire

Upload Enrollment Documentation Here

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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

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

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

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Choose a file or drag it here.

Previous School Information

Name of School & School Phone Number

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Please list any concerns and/or comments below:

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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 for "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."

Date*

ex. 01/05/2022

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Confirmation Email

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