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STOP!!! DO NOT BEGIN YOUR APPLICATION UNTIL YOU HAVE COLLECTED ALL REQUIRED DOCUMENTS. ONCE YOU SUBMIT YOUR APPLICATION YOU CANNOT RETURN TO IT TO CHANGE IT OR ADD DOCUMENTS. A complete list of all required documents may be found on our website. Applications will not be considered until all documents are received.

Please complete the following section about yourself, the primary adult.

First Name (Required)

Last Name (Required)

Birthday (Required)

Gender

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

Hispanic

English Proficiency

Other Language

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Lives with Family

Provides Financial Support

Teen Parent

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

Please answer the questions in the section below about the other adult/parent. The question "Lives with Family" means this person lives in the household with the child and the primary adult.

Is there another parent/guardian in the family?

First Name (Required)

Last Name (Required)

Birthday (Required)

Gender

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

Hispanic

English Proficiency

Other Language

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Lives with Family

Provides Financial Support

Teen Parent

Are there other adults in the household?

Add Another Adult

Use your income documents to determine your gross annual income, before taxes or other deductions. Be sure to include income from all adults that live with you and contribute to the total household income. If you are living with someone else, and they are not financially supporting you, you do not need to include them or their income on your application.

Number of Parents/Guardians

Relationship to Participant(s)

Primary Language at Home

Number in Household

Number in Family

Gross Annual Income

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

Is your family receiving Supplemental Security Income (SSI)?

Is your family receiving services from WIC?

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

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?

Add Emergency Contact

Please answer the questions below about your child.

First Name (Required)

Middle Name

Last Name (Required)

Birthday (Required)

Gender

Race

Hispanic

Other Language

Primary Health Coverage

Other Coverage

Medicaid Eligibility

Doctor/Medical Home

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

Thank you for your application. Please ensure you have submitted all required documents. Documents may be uploaded to your application or dropped off at our office located at 521 N. Burnside Avenue, Gonzales, LA 70737

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Other Adults

Family Information

Emergency Contacts

Child (Applicant)

Location Preferences

Additional Applicant

Siblings