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Early Connections - Application for Enrollment

A $10 application fee is required for processing. Please mail the
application fee to the address at the bottom of the form.

I am interested in

I am applying for the

Child's Information

First Name:
Middle Name:
Last Name:

Date of Birth: Month

Day

Year

Sex:

Race/Ethnicity:

Parents are:

Mother's Information

First Name:
Middle Name:
Last Name:

Address:
City:	State:	Zip:
County:

Home Phone:	- -
Cell Phone:	- -
Work Phone:	- -

Email Address:
Highest Grade Completed:
Degree Obtained:
Legal Guardian:

Employer:
Job Title:		Full time Part time N/A

Father's Information

First Name:
Middle Name:
Last Name:

Address:
City:	State:	Zip:
County:

Home Phone:	- -
Cell Phone:	- -
Work Phone:	- -

Email Address:
Highest Grade Completed:
Degree Obtained:
Legal Guardian:

Employer:
Job Title:		Full time Part time N/A

Guardian's Information (if different from above)

First Name:
Middle Name:
Last Name:

Address:
City:	State:	Zip:
County:

Home Phone:	- -
Cell Phone:	- -
Work Phone:	- -

Email Address:
Highest Grade Completed:
Degree Obtained:

Employer:
Job Title:		Full time Part time N/A

General Information

Because Early Connections is committed to serving a diverse group of children and also must meet certain requirements due to external funding sources, please complete the following information that is applicable to you and your family so that we may consider your child for enrollment based on these criteria.

I am a resident of Lamar County who is not employed by the school district.
Yes No
I am a Lamar County School District employee.
Yes No
*If you answered yes to this statement, please proceed to the Household Income Section and complete the required information.
I am a Teen mom that attends or has attended a Lamar County School.
Yes No
*If you answered yes to this statement, please respond to the following statements on your current status or your status pending the enrollment of your child into Early Connections. If you answered no, please proceed to the Household Income Section and complete the required information.
1. I am in high school or will be re-entering high school.
  Yes No
  *If yes, please list school and Last Grade completed.
  School name:
  Last grade completed:
2. I am getting my GED & seeking employment.
  Yes No
  If yes, please list Program, Enrollment Date, Hours of program and Expected Completion Date.
  Program:
  Enrollment Date:
  Hours of Program:
  Completion Date:
3. I am going to college full-time (12 or more hours).
  Yes No
  *If yes, please list School and Enrollment Date.
  School:
  Enrollment Date:

Household income:

* Please send proof of income to the address listed below if you are seeking scholarship funds for your child’s tuition.
* Early Connections accepts Childcare Assistance Vouchers from The District and will help families who qualify obtain the funding.

Number of people in household:

Please list any special needs your child might have including dietary needs:

If your child has a disability or a suspected disability, please contact Mrs. Terri Thomas at Lamar County Schools (601-794-8121) for a possible eligibility ruling for services under the Individual’s with Disability Education Act.

Please contact Jane Siders at (601) 266-5163 with any questions.

* Please mail the $10 application fee to the address below.

Mailing Address:

The University of Southern Mississippi
Early Connections
118 College Dr. #5163
Hattiesburg, MS 39406
Attn: Jane Siders

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If you have difficulty accessing any portions of this Web site due to incompatibility with adaptive technology or you need the information in an alternate format, please contact us at 601.266.6288 or email Richard.Baker@usm.edu.