Apply Online

Please complete all items to the best of your availability. Once completed you will be taken to the LESA Early Childhood Weebly website for more information on our program.

Please fill the in the following information for the Primary Adult in the household

First Name (Required)

Last Name (Required)

Birthday (Required)

Gender (Required)

Email Address (Required)

Confirm Email Address

It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.

Mobile Phone

Opt In for Text Messages

Home Phone

Work Phone

Ext.

It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.

Race (Required)

Hispanic (Required)

English Proficiency (Required)

Other Language

Highest Grade Completed (Required)

Employment Status (Required)

Child's Relationship (Required)

Custody

Lives with Family

Provides Financial Support

Teen Parent

Displaced/homeless examples: living with family/friends, LACASA, motel/hotel/shelter.

Is your family experiencing homelessness?

Living Address (Required)

Address Line 2

City (Required)

State (Required)

ZIP (Required)

Click here to find a provider in your area.

Mailing Address same as Living Address

Mailing Address

Address Line 2

City

State

ZIP

Is there another parent/guardian in the family?

First Name (Required)

Last Name (Required)

Birthday (Required)

Gender (Required)

Email Address

Confirm Email Address

It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.

Mobile Phone

Opt In for Text Messages

Home Phone

Work Phone

Ext.

It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.

Race (Required)

Hispanic (Required)

English Proficiency (Required)

Other Language

Highest Grade Completed (Required)

Employment Status (Required)

Child's Relationship (Required)

Custody

Lives with Family

Provides Financial Support

Teen Parent

Are there other adults in the household?

Add Another Adult

Number of Parents/Guardians

Relationship to Participant(s)

Primary Language at Home (Required)

Is another language being acquired or learned at home?

Number in Family (Required)

Gross Annual Income

Is your family receiving cash benefits or other services under the Temporary Assistance for Needy Families (TANF) program? (Required)

Is your family receiving Supplemental Security Income (SSI)? (Required)

Is your family receiving services from WIC? (Required)

Is your family receiving services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps? (Required)

Is at least one parent/guardian an active duty member of the United States military?

Is at least one parent/guardian a veteran of the United States military?

Under Primary Health Coverage Drop Down: If you receive Medicaid or MiChild (MiChild there is a monthly co-pay) ONLY you choose "Combined Medicaid/CHIP." in the drop down. If you receive Medicaid or MiChild and Private Health Insurance you will choose "Private Health Insurance" ONLY. If you receive Tri-Care or Children's Special Health Care Services Insurance you will chose "Other". All others will chose "Private Health Insurance" if that is what your child receives, or "No Insurance" at all.

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Nickname

Birthday (Required)

Gender

Race (Required)

Hispanic (Required)

English Proficiency (Required)

Other Language

Other Language Proficiency

Primary Health Coverage

Other Coverage

Insurance Number

Medicaid Eligibility

Medicaid Number

Doctor/Medical Home

Dental Coverage

Dental Coverage Number

Dentist/Dental Home

Does your child have a disability or do you have any concerns about your child's development?

Is there anything else you want to tell us about your child?

Which program are you applying for? (Required)

Location Preference

1st Location Preference

2nd Location Preference

3rd Location Preference

- Your Address - Available Locations

Click a location on the map to see more info

Click here to find a provider in your area.

Do you want to apply now for another child in your family?

Add Another Applicant

Are there other children in the family?

Add a Sibling

Once you submit your application an LESA Early Childhood staff member will send you your next steps towards enrollment.

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Other Adults

Family Information

Child (Applicant)

Location Preferences

Additional Applicant

Siblings