MEO HEAD START ENROLLMENT APPLICATION

MEO HEAD START ENROLLMENT APPLICATION
Family ID#
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Aloha,

Thank you for your interest in our MEO Head Start program! Please read these guidelines before completing an application for your child.
- Application must be completed by the child's parent or legal guardian.
- Review the MEO Head Start Selection Criteria. By clicking the submit button, you agree to the program terms & conditions.
- Contact our Head Start office at (808) 249-2988 should you have any questions regarding the selection criteria.
- Additional contact information should be someone other than the parents/legal guardians.
The following documents are required to complete your application:
- Your child’s birth certificate, hospital certificate or other document verifying child’s age.
- Income verification - copy of parent/guardians 2021 income tax returns 1040 (submit the page that lists your name/s, dependents, Wage, salaries, tips, not the whole packet) OR all W-2 forms.
- When applicable - TANF (AFDC Benefit History), SSI Benefit statement, Foster Care or Homeless Verification, Child Support distribution statement
- Someone from our program will contact you should there be questions or additional information needed.
Thank you!
Selection Criteria for School Year 2022-2023
Child's Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Gender *

Male Female
Race *

White Multi-Racial/Bi-Racial African American or Black Asian Hawaiian Pacific Islander American Indian Alaskan Native Unknown Other
Ethnicity: Hispanic or Latino *

Yes No
Primary Language Spoken at home *
Secondary Language Spoken at home *
Child's Health Information *

Quest Private None
Insurance Provider *
Primary Care Physician *
Dentist *
Developmental Concerns
Does your child have any current or chronic medical conditions? (Ex:asthma, food allergy, special diet, heart problems, seizures, etc.) *

Yes No
If you answered "Yes" to the question above, please list and explain
If you answered yes, would your child require medication during school hours?

Yes No
Does your child have any developmental concerns? (Ex: speech, hearing,vision, autism, injuries, etc.) *

Yes No
If you answered "Yes" to the question above, please list and explain
Does your child have a current Individual Education Plan (IEP)? *

Yes No
Does your child require any special accommodations in the classroom? *

Yes No
If you answered "Yes" to the question above, please list and explain
Family Information
Parental Status *

Single Female Single Male Two Parent Household Non-Parent Grandparent Foster Relative
Child Lives With *

Both Parents Mother Father Grandparent Non-Parent Foster
Custody - if not two parent household *

Mother Father Dual Custody Other Custody
Total Number in Family - include all individuals financially supported by the applicant's parent or guardian(s) *
Living situation *

Own Rent Public Housing Permanent housing shared with family Temporary Housing Transitional housing, Emergency shelter
Services your family receives (Select all that apply) *

WIC SNAP TANF SSI HUD CWS Child Support None
Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Living Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
(A01) Parent/Guardian Information
(A01) Parent/Guardian *

Mother Father Grandparent Foster
(A01) Name *

First Name Last Name
(A01) Parent/Guardian Home Phone *

Area Code Phone Number
(A01) Parent/Guardian Work Phone *

Area Code Phone Number
(A01) Parent/Guardian Cell Phone *

Area Code Phone Number
(A01) Parent/Guardian Opt in for Text Messages *

Yes No
(A01) Email *
example@example.com
(A01) Date of Birth *

Month Day Year
Date
(A01) Gender *

Male Female
(A01) Race *

White Multi-Racial/Bi-Racial African American or Black Asian Hawaiian Pacific Islander American Indian Alaskan Native Unknown Other
(A01) Ethnicity: Hispanic or Latino *

Yes No
(A01) Current Employment Status *

Full-time Part-time Training School Retired Disabled Seasonal Unemployed Stay at home parent Member of US Military (Active Duty) Veteran of US Military
(A01) Hours of employment *
(example: Monday –Friday 7:30-3:30)
(A01) Current EducationLevel *

Grade 9 or less Grade 10 Grade 11 Grade 12 High School Diploma GED Vocational School Some College Associates Degree Baccalaureate Degree Advanced Degree
(A01) Health Information *

Quest Private None
(A01) Insurance Provider *
(A02) Parent/Guardian Information
(A02) Parent/Guardian

Mother Father Grandparent Foster
(A02) Name

First Name Last Name
(A02) Parent/Guardian Home Phone

Area Code Phone Number
(A02) Parent/Guardian Work Phone

Area Code Phone Number
(A02) Parent/Guardian Cell Phone

Area Code Phone Number
(A02) Parent/Guardian Opt in for Text Messages

Yes No
(A02) Email
example@example.com
(A02) Date of Birth

Month Day Year
Date
(A02) Gender

Male Female
(A02) Race

White Multi-Racial/Bi-Racial African American or Black Asian Hawaiian Pacific Islander American Indian Alaskan Native Unknown Other
(A02) Ethnicity: Hispanic or Latino

Yes No
(A02) Current Employment Status

Full-time Part-time Training School Retired Disabled Seasonal Unemployed Stay at home parent Member of US Military (Active Duty) Veteran of US Military
(A02) Hours of employment
(example: Monday –Friday 7:30-3:30)
(A02) Current EducationLevel

Grade 9 or less Grade 10 Grade 11 Grade 12 High School Diploma GED Vocational School Some College Associates Degree Baccalaureate Degree Advanced Degree
(A02) Health Information

Quest Private None
(A02) Insurance Provider
Additional dependents supported by Parent(s) or Guardian(s)
Additional Contact Information (Name, Address, Phone) *
You may upload required documents below, email to hsapp@meoinc.org, or drop off at the MEO Head Start office.
You may upload required documents here, in the form of Photos or PDF files *

Browse Files

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Parent/Guardian’s Signature *

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MEO HEAD START ENROLLMENT APPLICATION

Selection Criteria for School Year 2022-2023

Developmental Concerns

Family Information

(A01) Parent/Guardian Information

(A02) Parent/Guardian Information