Iberia Parish Early Childhood Community Network Coordinated Enrollment Application Thank you for your interest in applying for Public Pre-K seats. To apply using this application… • Print each page individually (single sided) • Complete the forms • Attend the Pre-Kindergarten Round-Up Event o March 18, 19, & 20, 2020 • If after the Pre-Kindergarten Round-Up Event, contact Molly Blanchard or Beth Douzart at (337) 364-7641 to schedule an appointment. NOTE: If applying for Child Care, Early Head Start, or Head Start, click on the “Coordinated Enrollment Application” link for the application.
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Iberia Parish Early Childhood Community Network Coordinated Enrollment Application
Thank you for your interest in applying for Public Pre-K seats. To apply using this application… • Print each page individually (single sided) • Complete the forms • Attend the Pre-Kindergarten Round-Up Event
o March 18, 19, & 20, 2020 • If after the Pre-Kindergarten Round-Up Event, contact
Molly Blanchard or Beth Douzart at (337) 364-7641 to schedule an appointment.
NOTE: If applying for Child Care, Early Head Start, or Head Start, click on the “Coordinated Enrollment Application” link for the application.
Iberia Parish Public Schools ~ Pre-Kindergarten Program
Thank you for registering with the Iberia Parish Pre-Kindergarten Program. The following documents are needed in order to process the application:
Coordinated Enrollment Application Income Eligibility Survey Birth Certificate Parent/Guardian Driver’s License Social Security Card Proof of Residence – Gas, Water, or Electric ONLY
Must include the “Service Address” and be in the parent/guardian’s name Immunization Record
Official with State Seal, Expiration Date & Signature Proof of Income Documents ~ Acceptable Forms:
Check Stubs ~ 2 current & consecutive check stubs (within 2 months of filling out the application) for EACH parent or caregiver in the household.
Official Employment Letter ~ MUST include place of employment, hourly rate of pay, the average number of hours worked per week. Signed & Dated.
SNAP/Food Stamps Report ~ Detailed Report that MUST include child’s name and valid effective dates.
Social Security Administration Statement ~ Current & Detailed Report verifying that the child listed on the application is a recipient. SS benefits for any other household member(s) MUST be accompanied by two current check stubs OR SSI Only Statement as applicable.
Foster Care Placement Agreement ~ Current from DCFS Homeless ~ Families in a temporary living arrangement due to loss of housing
or economic hardship. Homeless paperwork completed and verified by the LEA. Other ~ Parents or guardians who are unemployed, employed intermittently,
self-employed, who don’t have check stubs or benefits print outs to verify income, MUST submit a Declaration of Income for Irregular Employment Form along with a Statement of Support/Statement of No Income Form as applicable.
IPSB Pre-K Application Iberia 3 form Pre-K Medical Information Form Migrant Recruitment Form Home Language Survey Residency Questionnaire
To Submit a Completed Application:
Round-Up Days (March 18, 19, & 20, 2020) Maintenance Building (413 S. Lewis Street) 9:00 a.m. – 2:00 p.m.
Check All That Apply Mother Father Both Other (specify)
PARENT/GUARDIAN INFORMATION #1 Full Name: Last First Relationship to Child
Physical Address: Street City Zip Code
Mailing Address: Street City Zip Code
Phone Numbers: Home Cell Work
e-mail Address:
PARENT/GUARDIAN INFORMATION #2 Full Name: Last First Relationship to Child
Physical Address: Street City Zip Code
Mailing Address: Street City Zip Code
Phone Numbers: Home Cell Work
e-mail Address:
Matching Based on Preference
What are you applying for? Please list programs in order of YOUR preference.
For Child Care list the name of the center.
For Early Head Start list Early Head Start & the site location (Jeanerette, New Iberia, Second Street).
For Head Start list Head Start & the site location (Jeanerette, New Iberia, Second Street).
For Public Pre-K list Public Pre-K & the school that you are zoned for.
Choice #1:
Choice #2:
Choice #3:
Signature (Adult MUST Sign)
I, the undersigned, confirm that the information provided on this form is true and correct. I understand that sharing the information I have provided in this application across early childhood programs in my community will facilitate matching my child to a seat, and I hereby give permission for the information provided here to be shared with the programs in the Iberia Parish Early Childhood Community Network.
Parent/Guardian Signature: Date
DO NOT COMPLETE – FOR NETWORK USE ONLY
I confirm that the information provided on this form has been reviewed and verified. I understand that I may be audited for accuracy and eligibility.
Birth Certificate Verified: Proof of Residence Verified: School Zone:
Person Verifying Application: Date:
Coordinated Enrollment Application Page 1
Revised January 2020
PLEASE USE BLUE OR BLACK INK ONLY
Child’s Name: Check if Applicable
Foster Child
As It Appears on Birth Certificate
Last
First
Homeless Child
Child’s Age on Sept. 30th : If checked, provide documentation & skip to Part 3.
Instructions for completing this document. 1. Submit Proof of Income documents with the application. The following documents are allowable/acceptable:
a. Check Stubs – 2 Consecutive & Current for EACH parent or caregiver in the household. b. Official Employment Letter – stating where the parent/guardian is employed, the hourly rate of pay, and the average number of hours the
parent/guardian works per week. (SIGNED & DATED BY EMPLOYER) c. Social Security Administration Statement – verifying that the child listed on the application is a recipient of the SSI benefits, which MUST be
accompanied by two current check stubs. d. SNAP/Food Stamps Report – MUST include the child’s name and valid effective dates. e. Foster Care Placement Agreement – Current from DCFS. f. Homeless – Families in a temporary living arrangement due to loss of housing or economic hardship. Homeless paperwork completed and
verified by the LEA. g. Other – Parents or guardians who are unemployed, employed intermittently, self-employed, who don’t have check stubs or benefits print outs
to verify income, MUST submit a Declaration of Income for Irregular Employment Form along with a Statement of Support form if applicable. 2. Complete document to fullest extent.
Part I. If any member of your household receives SNAP, FDPIR or FITAP assistance, please complete this section. Submit documentation and skip to Part 3. If no one receives these benefits, continue to Part 2.
Name of Person Receiving Benefits: Program Name:
Part 2. Household GROSS Income Verification a) List all income (before deductions) on the same line as the person who receives it. b) Check the box for how often it is received. c) Record each income only once.
Names of Household Members WITH Income
Employer Name
Earnings from
WORK before
deductions Wee
kly
Eve
ry 2
Wee
ks
Tw
ice
Mo
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ly
Mo
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Welfare, Child
Support, alimony
Wee
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Eve
ry 2
Wee
ks
Tw
ice
Mo
nth
ly
Mo
nth
ly
Social Security, SSI, VA,
retirement benefits W
eekl
y
Eve
ry 2
Wee
ks
Tw
ice
Mo
nth
ly
Mo
nth
ly
All other income
Wee
kly
Eve
ry 2
Wee
ks
Tw
ice
Mo
nth
ly
Mo
nth
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Household Members WITHOUT Income – List Names and Circle the category that applies
Adult Child Adult Child
Adult Child Adult Child
Adult Child Adult Child
Part 3. Number in Household # of Children in Family
Household Members with Income Total Family Size (ALL MEMBERS)
Part 4. Signature (ALL ADULTS LISTED ABOVE MUST SIGN)
I, the undersigned, confirm that the information provided on this form is true and correct. I understand that sharing the information I have provided in this application across early childhood programs in my community will facilitate matching my child to a seat, and I hereby give
permission for the information provided here to be shared with the programs in the Iberia Parish Early Childhood Community Network.
Parent/Guardian Signature(s): Date
DO NOT COMPLETE – FOR NETWORK USE ONLY
Based on the Income Eligibility Survey and the documentation provided, the family MAY QUALIFY for:
100% 130%
CCAP (Birth – 4 yrs.) Early Head Start (Birth – 3 yrs.) Public Pre-K (Tuition NOT Required) (4 yrs.)
Child Care with Tuition (Birth – 4 yrs.) Head Start (3 yrs. – 4 yrs.) Public Pre-K (Tuition MAY BE Required) (4 yrs.)
I confirm that the information provided on this form has been reviewed and verified. I understand that I may be audited for accuracy and eligibility.
Child’s Full Name: Male Female As It Appears on Birth Certificate
Last First Middle Child’s Gender
Child’s Date of Birth: Month Day Year Child’s Current Age
Child’s Ethnicity: Black/African American White Hispanic
American Indian/Alaskan Native Asian/Pacific Islander
Child’s Primary Language:
Child lives with: Mother Check all that apply Print Name Phone #
Father Print Name Phone #
Other Print Name Phone #
Physical
Street City Zip Code
Mailing Address: If different from
Physical Address Street City Zip Code
IPSB Employee? YES (Indicate Where? ________________________________) NO
Emergency Numbers Name Relationship Phone Number(s)
If the child was in any type of non-parental care for a period of 6 months or longer before entering the pre-kindergarten program, please check those that apply.
Child Care Center Home with Me Outside the Home with Sitter
Head Start Home with Sitter Other:
Does child have IEP with IPSB? YES NO
If the child has any siblings currently attending school please list below:
Child’s Name School Grade
Parent/Guardian Signature: Date
DATE:_______________________________ Form Iberia 3 (Revised 4/18) REGISTRATION OR TRANSFER AND REQUEST
Please read carefully before completing the following blanks. PLEASE PRINT Certified Birth Certificate and Social Security Card is required for all children entering public schools, even if from outside the parish, parochial schools or private schools regardless of grade. STUDENT NAME______________________________________________________ Foster Care Student ____YES____NO LAST FIRST MIDDLE SIGNATURE OF PARENT OR GUARDIAN________________________________________________________________________ PARENT’S EMAIL ADDRESS__________________________________________________________________________________ Has this child or any other child of yours ever attended an Iberia Parish Public School? _____YES _____NO If yes, name of school and date of attendance_________________________________________________________________________________________ Has this child ever received special education services? _____YES ______NO What service(s)?_________________________________________________ Has your child received these services in the last three years? _____ YES ______NO DATES:____________________________________________________ ________________________________________________________________________________________________________________________________THE FOLLOWING INFORMATION MUST BE EXACTLY AS IT IS ON THE STUDENT’S BIRTH CERTIFICATE: Father____________________________________________________________________________ Alive? _____ YES _____ NO LAST MIDDLE FIRST Mother___________________________________________________________________________ Alive? _____ YES _____ NO LAST MIDDLE FIRST Birth Certificate Number_____________________________________________________________ Date of Birth_________________________________________ Place of Birth_________________________________ Country____________________ CITY STATE MOTHER’S EMPLOYER____________________________________________________ EMPLOYER’S PHONE _______________________________________ MOTHER’S MILITARY AFFILIATION (please check if applicable) Active Duty ________ Retired ________ Reserves ________ FATHER’S EMPLOYER_____________________________________________________ EMPLOYER’S PHONE NUMBER________________________________ FATHER’S MILITARY AFFILIATION (please check if applicable) Active Duty ________ Retired ________ Reserves ________ STUDENT INFORMATION: Is the student Hispanic? __ Yes __ No If no, select one primary race. Select all applicable secondary races. SS# _____-___-_____ Sex___ Primary Language_____ Primary Race: Secondary Race: Physical Address______________________________________________ ___ White ___ White (IF DIFFERENT FROM ABOVE) ___ Black ___ Black ___ Asian ___ Asian Mailing Address______________________________________________ ___ Native American/Alaskan ___ Native American/Alaskan Phone: Home_______________ Work _________________ Cell_____________ ___Hawaiian/Pacific Islander ___ Hawaiian/Pacific Islander
NAME AND RELATIONSHIP OF PERSON WITH WHOM CHILD LIVES WITH IF OTHER THAN PARENT: _________________________________________________________________________________________________________ NAME RELATIONSHIP TO STUDENT EMAIL ADDRESS___________________________________________________________________________________________ Emergency Contact ____________________________________________________ Phone ______________________ Relationship____________________ Family Doctor________________________________________________________ Phone_____________________________________________________
PREVIOUS SCHOOL INFORMATION: Moved from______________________________________________________________________________________________________________________ CITY PARISH/COUNTY STATE ________________________________________________________________________________________________________________________________ SCHOOL ADDRESSS PHONE/FAX
LEP CODE_____ SPED_____ 504_____ SPEECH_____ RESOURCE_____ SELF CONTAINED______ G/T______ SCHOOL #_____ GRADE_____ JPAMS SIDNO______________ HOMEROOM______________ BUS #________
IBERIA PARISH SCHOOL BOARD PRE-K MEDICAL INFORMATION SHEET
• Does this student have any health issues that we should be aware of? YES NO If yes, explain: ________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ DOES THIS CHILD: CIRCLE ONE: IF YES, EXPLAIN?
Have allergies
YES NO
Take medication
YES NO
Have physical handicap
YES NO
• Do you think your child might have a hearing problem? YES NO
• Has your child been under the care of a doctor/ear specialist for his ears? YES NO If yes, which doctor? ___________________________ When? __________________________ Describe problem: ______________________________________________________________ _____________________________________________________________________________
• Do you think your child has a vision problem? YES NO GLASSES? YES NO
• Has your child ever been under the care of an eye doctor? YES NO If yes, which doctor? ____________________________ When? __________________________ Describe: ______________________________________________________________________ ______________________________________________________________________________ Have your child’s eyes been checked by an eye doctor in the last 6 – 12 months? YES NO
• Are vaccinations up to date? YES NO ** Please note: There are immunizations due after the 4th birthday. Filled by: ________________________________________ Date: ___________________
(Revised: June 2018)
Iberia Parish School Board 1500 Jane Street
New Iberia, LA 70560
(337) 365-2341
Migrant Recruitment Form
SCHOOL: PARISH:
Have you moved in the past three (3) years? Yes No If your answer is YES:
A.) What is the city or town that you moved from?
B.) What is the city or town that you moved to?
Has ANY member of the immediate family ever worked in jobs related to Agriculture, Food Processing,
Commercial Fishing, Shrimping, Crawfishing, Seafood Processing, Ranching, Timber Production, Timber Harvest, or Similar Occupations? YES NO
If your answer is YES, please check any of the following occupations you or your spouse have WORKED IN
or INTEND TO WORK IN. AGRICULTURE COMMERCIAL FISHING
ATTENTION SCHOOLS: Please scan through email to Crystal Arceneaux at [email protected]
FOR OFFICE USE ONLY:
RECEIVED BY: _____________________________ DATE RECEVIED: ____________________
IBERIA PARISH SCHOOL BOARD Children First
Department of Curriculum
1204 LeMaire Street New Iberia, LA 70560-4813
Phone (337) 364-7641 Fax (337) 367-9611
Carey Laviolette Superintendent
Jennifer Joseph Assistant Superintendent
of Administration
Heath Hulin Assistant Superintendent
of Instruction
Date District/Parish School Name
Student Name SSN/ID#
Male/Female Date of Birth (D.O.B.) Address
Telephone Number Last School Attended Current Grade
Parent/Guardian/Adult Caring for Student Relationship
Disclaimer: This questionnaire is intended to address the McKinney-Vento Act. Your child may be eligible for additional educational services through Title I Part A, Title I Part C-Migrant, Individuals with Disabilities Education Act (IDEA) and/or Title X, Part C, Federal McKinney-Vento Assistance Act, 42 U.S.C.11435. Eligibility can be determined by completing this questionnaire. It is illegal to knowingly make false statements on this form. If eligible, students are to be immediately enrolled in accordance with Bulletin 741, section 341.
1. Yes No Is the student’s address a temporary living arrangement? (Note: If this is a permanent living arrangement or thefamily owns or rents their home, sign under item 9 and submit form to school personnel.)
2. Yes No Is the temporary living arrangement due to loss of housing or economic hardship?
3. Where is the student currently living? (Check all that apply)
In an emergency/transitional shelter. Awaiting foster care placement. Temporarily with another family because we cannot afford or find affordable housing.With an adult that is not a parent or legal guardian, or alone without an adult. In a vehicle of any kind, trailer park or campground without running water/electricity, abandoned building or substandard housing. Emergency Housing (i.e. FEMA Trailer or FEMA Rental Assistance) In a hotel/motel. Other specific information
4. Yes No Does your child have a disability or receive any special education services? (Check One)
5. Yes No Does your child exhibit any behaviors that may interfere with his or her academic performance?
6. Would you like assistance with uniforms student records school supplies transportation other?(Describe: )
7. Yes No Migrant - Have you moved at any time during the past three (3) years to seek temporary or seasonal work in agriculture(including poultry processing, dairy, nursery, and timber) or fishing?
8. Yes No Does your child have siblings (brothers or sisters)? Note: Use back of page if more space is needed.
Name Name Name
School School School
Grade Grade Grade
DOB DOB DOB
9. The undersigned certifies that the information provided above is accurate.
Print Parent/Guardian Name/Adult Caring for Student Signature Date
(Area Code) Phone number Street Address City State Zip
School Use Only Free or Reduced Price Meals Form submitted/signed Copy Placed in Student’s Cumulative Record
Homeless Liaison Use Only- Check A ll That Apply
Sheltered Doubled-Up Unsheltered/FEMA Hotel/Motel Unaccompanied Youth Yes No Awaiting Foster Care Placement
Print School Contact Title Signature (required) Date (Revised 11/2015)
IBERIA PARISH SCHOOL BOARD1204 LeMaire Street
New Iberia, LA 70560-4813Phone: (337) 367-7641 Fax (337) 367-9611
Louisiana Student Residency Questionnaire Form(Form Must Be Included In School Enrollment Packet)
