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
Homelessness examples: living with family/friends, LACASA, motel/hotel/shelter.
Click here to find a provider in your area.

Are there other adults in the household?

Add Another Adult
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.
- 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 contact you to schedule an application appointment.
Required information is missing, see above.