Oahu Head Start

Child/Parent Information

Please submit all the information to prevent the delay in processing the application.

Child's Name:
(First, Middle Initial, Last)

Date of Birth:
(MM/DD/YY)

Child Gender:

Male Female

Parent/Guardian Name:
(First, Middle Initial, Last)

Date of Birth:
(MM/DD/YY)

Parent Gender:

Male Female

Relationship to Child:

Living Address:

City:

Zip/Postal Code:

Mailing Address: If mailing address is same as living address mark checkbox,
if not fill in mailing address.

Mailing Address:

City:

Zip/Postal Code:

Home Phone:

Work Phone:

Cell Phone:

Email:

Other Contact Person's Name:

Other Contact Person's Phone:

Family Information

Fill out this section for all family memebers, excluding the child and the parent/guardian listed above.

Other Family Member Name: (First, Middle Initial, Last)	Date of Birth: (MM/DD/YY)	Gender: (M/F)	Relationship to the Applying Child:
1.
2.
3.
4.

Number of adults in your family:

Number of children in your family:

Online Application