Honolulu Community Action Program, Inc.
1132 Bishop St., Suite 100Honolulu, HI 96813
Tel: (808)847-2400, Fax: (808)847-2302
Early Head Start - Head Start Application
Identify Program applying for, check one: / If applicable the following documents will be required to process your application:Early Head Start, check Early Head Start category:
Prenatal Mom Children 0-34 months old
Head Start: Children 3-5 years old
(birthdates between: August 1, 2012 - December 31, 2014) / 1. Child's Birth Certificate
2. Copy of pay stubs for 12 months
3. Copy of last year's tax forms
4. TANF Payments for 12 months
5. Net income from self-employment
6. Child support and/or alimony payments / 7. Supplemental Security Income Documentation
8. College or university scholarships and/or grants
9. Documentation of Homelessness
10. Documentation of foster care
11. DOE IEP / DOH IFSP (if applicable)
12. Power of Attorney (if applicable)
Part A - Prenatal Mom or Child Applicant : Information about the pregnant mom or child who is applying
Foster Child
First Name: / Middle Initial: / Last Name:
Date of Birth: / Male / Female / Primary Home Language:
Secondary Home Language:
Ethnicity: / Hispanic or Latino origin / Yes / No
Race (check one):
American Indian or Alaskan Native / Native Hawaiian or Pacific Islander
Asian / White
Black or African American / Bi-Racial/Multi-Racial / Other:
Health Insurance (Check One): / Medicaid/Quest / Private / Military Health / No Health Insurance
Insurance Provider: / HMSA / Kaiser / Aloha Care / Tri-Care / Other:
Policy/Medical Record Number:
Part B - Family Information
Living Address: / Currently Homeless:
Shelter/Vehicle
Mailing Address: / Park/Beach/Motel/Hotel
(if different from above) / Has means of Transportation / Yes No
Part C - Prenatal Mom or Primary Guardian: Information about the pregnant mom or adultresponsible for applying child
First Name: / Middle Initial: / Last Name:
Date of Birth: / Male / Female
Contact Phone: / Text: Yes / No / E-mail Address:
Ethnicity: / Hispanic or Latino origin / Yes / No
Race (check one):
American Indian or Alaskan Native / Native Hawaiian or Pacific Islander
Asian / White
Black or African American / Bi-Racial/Multi-Racial / Other:
Highest Grade completed in school (check one)
Grade 9 or less / Grade 10 / Grade 11 / GED / High School Graduate
Associate's Degree / Bachelor's Degree / Master's Degree (or above) / Training Certificate
Employment Status (check all that apply):
Full-Time Work (35+hrs/wk or more) / Training or in school / Retired or Disabled
Part-Time Work (Under 35 hrs/wk) / Seasonally Employed / Stay at home parent
Unemployed / Self-Employed Military Status: Active Veteran
Relationship to child or Prenatal Status:
Biological Parent / Adoptive Parent / Step Parent / Foster Parent / Grandparent
Other:
Does the child live with you? / Yes / No / Part Time
Do you have the same home address as the child? / Yes / No
If No, please provide current address:
Office use only
Date received: / Site: / Inputted By:
Part D - Secondary Guardian: Information about the secondary adult or adult responsible for applying child
First Name: / Middle Initial: / Last Name:
Date of Birth: / Male / Female
Contact Phone: / Text: Yes / No / E-mail Address:
Ethnicity: / Hispanic or Latino origin / Yes / No
Race(check one):
American Indian or Alaskan Native / Native Hawaiian or Pacific Islander
Asian / White
Black or African American / Bi-Racial/Multi-Racial / Other:
Highest Grade completed in school (check one)
Grade 9 or less / Grade 10 / Grade 11 / GED / High School Graduate
Associate's Degree / Bachelor's Degree / Master's Degree (or above) / Training Certificate
Employment Status (check all that apply):
Full-Time Work (35+hrs/wk or more) / Training or in school / Retired or Disabled
Part-Time Work (Under 35 hrs/wk) / Seasonally Employed / Stay at home parent
Unemployed / Self-Employed Military Status: Active Veteran
Relationship to child:
Biological Parent / Adoptive Parent / Step Parent / Foster Parent / Grandparent
Other:
Does the child live with you? / Yes / No / Part Time
Do you have the same home address as the child? / Yes / No
If No, please provide current address:
Parental Status: / Two Parent / One parent / Foster / Grandparent/Relative
Housing: / Own / Rent / Public Housing (section 8, subsidized, etc.)
Make no payment / Live with relative/friend
Has your child been identified by a professional as having a disability or special need? / Yes / No
If Yes, please explain:
Part E - Other Family Members Supported By Guardian’s Income
First, Middle Initial & Last Name / Relationship to applying child or pregnant mom / Date of Birth / Gender (M/F)
Please check all services your family currently receives:
None / TANF / Food Stamps/SNAP / WIC / Child Welfare Services (open case)
Supplemental Security Income (SSI) / Other:
# Of Adults in the family / # Of Children in the family / Estimated annual Income
How did you hear about the program? / Early Head Start / Family or Friend / Flyers HCAP Staff
HCAP Website / Social Media / Walk in / Other:
Agency / Referring Agency: / Contact: / Ph #:
DOE / Referring Agency: / Contact: / Ph #:
Early Intervention / Referring Agency: / Contact: / Ph #:
I understand that the information in this application will be held in strict confidence within the agency. I further understand that this is an application for services that are paid for with federal funds and that intentionally providing misleading, inaccurate or untruthful information of a material nature could result in disenrolling my child from Head Start and could have serious legal consequences for me.
HCAP does not discriminate on the basis of race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.
Parent/Guardian Signature: / Date: / gngngnvdvdvdvvddv