HCAP Head Start Online Application

Child Information

Please fill out the information below for the child applying to HCAP Head Start.

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

Date of Birth:
(MM/DD/YY)

Child Gender:

Male Female

Is the applying child a Foster Child:

Yes

Child's Primary Language at home:

Child's Secondary Language at home:

Child's Race/Ethnicity:

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Pacific Islander

White

Hispanic/Mexican

Other

Child's Health Insurance:

Medicaid/Quest

Private

Military Health

No Health Insurance

Child's Insurance Provider:

HMSA

Kaiser

Aloha Care

Tri-Care

Other

Policy Number:

Does your child have a secondary insurance?:

Yes

Child's Secondary Insurance Provider:

HMSA

Kaiser

Aloha Care

Tri-Care

Other

Family Information

Fill out this section with the current Family Information of the appliying child

Living Address:

City:

Zipcode:

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

Mailing Address:

City:

Zipcode:

Home Phone:

Work Phone:

Cell Phone:

Are you Currently Homeless?:
(Car,Shelter,Motel/Hotel)

Yes

Is one Parent/Guardian of the applying child in the Military?: Yes

Primary Adult

Fill out this section for the Primary Adult/Guardian/Caretaker of the appliying child.

Primary Adult Name:
(Last, First, Middle)

Date of Birth:
(MM/DD/YY)

Primary Adult Gender Male

Female

Primary Adult Race/Ethnicity:

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Pacific Islander

White

Hispanic/Mexican

Other

Employment Status:
(Check all that apply)

Full time Work (36+hrs/wk or more)

Part Time Work (Under 36 hrs/wk)

Seasonally Employed

Training or in School

Unemployed (Looking for Employment)

Retired or Disabled

Not Employed (Stay Home)

Relationship to Child:
(Check one)

Biological Parent

Adoptive Parent

Step Parent

Foster Parent

Grandparent

Other

Does the Child Live with you?:

Yes

Part Time

Do you have the same home and mailing address as the child?:

Yes

If No please Provide current address:

Secondary Adult

Please fill out this section for the Secondary Adult to the appliying child. If you are a single parent you can skip this section.

Secondary Adult Name:
(Last, First, Middle)

Date of Birth:
(MM/DD/YY)

Secondary Adult Gender Male

Female

Secondary Adult Race/Ethnicity:

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Pacific Islander

White

Hispanic/Mexican

Other

Employment Status:
(Check all that apply)

Full time Work (36+hrs/wk or more)

Part Time Work (Under 36 hrs/wk)

Seasonally Employed

Training or in School

Unemployed (Looking for Employment)

Retired or Disabled

Not Employed (Stay Home)

Relationship to Child:
(Check one)

Biological Parent

Adoptive Parent

Step Parent

Foster Parent

Grandparent

Other

Does the Child Live with you?:

Yes

Part Time

Do you have the same home and mailing address same as the child?:

Yes

If No please Provide current address:

Please check all services your family currently receives:

Child Welfare Services (open case)

Food Stamps/SNAP

Supplemental Security Income (SSI)

TANF

WIC

Other

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

Does your child recieve special education services through DOE?:

Yes

If Yes to above question:
Does your child currently
have an IEP?:

Yes what school:

Other Children

Fill out this section with siblings information of the applying child, excluding the applying child listed above.

Other Children's Name: (Last, First, Middle)	Date of Birth: (MM/DD/YY)	Gender: (M/F)	Relationship to the Applying Child:
1.
2.
3.
4.
5.

How did you hear about us?:

Agency Referral
The Bus
Early Intervention
Family or Friend
Flyers
Other

Number of adults in your family:

Number of children in your family:

Estimated Annual Income:

Online Application

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Honolulu Community Action Program

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