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Early Childhood Education Application 2026-2027

Cameron Parish Coordinated Enrollment Application-Early Childhood

The following link will open into a new window. This questionnaire MUST be completed for students entering a 4 year old program (Pre-K or Head Start 4 year old class) only before registration.

Early Childhood Registration Developmental Questionnaire

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*

Answer required for "First Name"

Middle Name*

Answer required for "Middle Name"

Gender*

Answer required for "Gender"

Male

Female

Date of Birth*

Answer required for "Date of Birth"

Place of Birth*

Answer required for "Place of Birth"

SSN

Answer required for "SSN"

Mother's Maiden Name*

Answer required for "Mother's Maiden Name"

Race of Child: (check all that apply)*

Answer required for "Race of Child: (check all that apply)"

White

Black

Native Am/Alaskan

Hawaiian/Pacific Islander

Hispanic

Asian

First language spoken by student*

Answer required for "First language spoken by student"

Languages spoken at home*

Answer required for "Languages spoken at home"

Street Address*

Answer required for "Street Address"

City*

Answer required for "City"

State*

Answer required for "State"

Zip/Postal*

Answer required for "Zip/Postal"

Parent/Guardian 1 Info

First Name*

Answer required for "First Name"

Last Name*

Answer required for "Last Name"

Address Same as Student

Answer required for "Address Same as Student"

Yes

Street Address

Answer required for "Street Address"

City

Answer required for "City"

State

Answer required for "State"

Zip/Postal Code

Answer required for "Zip/Postal Code"

Email Address*

Answer required for "Email Address"

Mobile Phone*

000-000-0000

Number Required

Work Phone

000-000-0000

Number Required

Relation to Child:*

Answer required for "Relation to Child:"

Employer*

Answer required for "Employer"

Does student live with this person?*

Answer required for "Does student live with this person?"

Parent/Guardian 2 Info

First Name*

Answer required for "First Name"

Last Name*

Answer required for "Last Name"

Address Same as Student

Answer required for "Address Same as Student"

Yes

Street Address

Answer required for "Street Address"

City

Answer required for "City"

State

Answer required for "State"

Zip/Postal Code

Answer required for "Zip/Postal Code"

Email*

Answer required for "Email"

Mobile Phone*

000-000-0000

Number Required

Work Phone

000-000-0000

Number Required

Relation to Child:*

Answer required for "Relation to Child:"

Does student live with this person*

Answer required for "Does student live with this person"

PARENTAL STATUS OF MOTHER AND FATHER*

Answer required for "PARENTAL STATUS OF MOTHER AND FATHER"

Single

Married

Separated

Divorced

Emergency Contact Info

Contact #1 Name - First & Last*

Answer required for "Contact #1 Name - First & Last"

Relationship to student*

Answer required for "Relationship to student"

Email 1

Answer required for "Email 1"

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*

Answer required for "Contact #2 Name - First & Last"

Relationship to student*

Answer required for "Relationship to student"

Email 1

Answer required for "Email 1"

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*

Answer required for "Family Size"

Total Adults*

Answer required for "Total Adults"

Number of Children*

Answer required for "Number of Children"

Ages of Children*

Answer required for "Ages of Children"

Are you and your family:

Answer required for "Are you and your family:"

Foster Family

Homeless/Doubled-Up/Inadequate housing

Do you receive: (please check all that apply)

Answer required for "Do you receive: (please check all that apply)"

SSI

FITAP/TANF

SNAP

WIC

N/A

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

Answer required for "Is your child covered by medical insurance? If yes, provide name."

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

Answer required for "Is your family covered by medical insurance? If yes, provide name. "

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:*

Answer required for "Does your child have a current:"

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"

Head Start Enrollment Documents - upload or bring directly to the centers.

For Cameron Parish Pre-K, Enrollment Documentation must be uploaded:

1. Proof of Income

2. Birth Certificate

3. Up-to-date Immunization Record

4. Proof of Residency -2 required.

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

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

Upload Enrollment Documentation Here

Use a Scanner or Cell Phone Notes App- Scan Document feature

Answer required for "Upload Enrollment Documentation Here"

Choose a file or drag it here.

Proof Residency Required (2 required)

-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, water, and/or gas)

-Current lease or mortgage statement

Upload Residency Documents Here

Answer required for "Upload Residency Documents Here"

Choose a file or drag it here.

Proof of Income for all adults living in the home is required. Please check proof of income that applies below.*

Answer required for "Proof of Income for all adults living in the home 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 all adults here

Answer required for "Upload Proof of Income for all adults here"

Choose a file or drag it here.

Previous School Information

Name of School & School Phone Number

Answer required for "Previous School Information"

Please list any concerns and/or comments below:

Answer required for "Please list any concerns and/or comments below:"

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. 01/05/2025

Answer required for "Date"

Confirmation Email

Answer required for "Confirmation Email"

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