MEO HEAD START ENROLLMENT APPLICATION 2024

MEO HEAD START ENROLLMENT APPLICATION
Current Date

MonthDayYear
Date
Family ID#
CENTER PREFERENCE
Selection Criteria for School Year 2024-2025
Aloha,

Thank you for your interest in our MEO Head Start program! Please read these guidelines before completing an application for your child.
- 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.
- Additional contact information should be someone other than the parents/legal guardians.
The following documents are required to submit with your application:
- Your child’s birth certificate, hospital certificate or other document verifying child’s age.
- Income verification - copy of parent/guardians 2023 income tax returns 1040 (submit the page that lists your name/s, dependents, wage, salaries, tips, not the whole packet) OR all 2023 W-2 forms.
- When applicable - TANF (AFDC Benefit History), SSI, SNAP Benefit statement, Foster Care, Homeless Verification, or Child Support distribution statement.
- Someone from our program will contact you should there be questions or additional information needed.
Thank you!
Child's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Race*

WhiteMulti-Racial/Bi-RacialAfrican American or BlackAsianHawaiianPacific IslanderAmerican IndianAlaskan Native
Ethnicity: Hispanic or Latino*

YesNo
Primary Language Spoken at home*
Secondary Language Spoken at home*
Child's Health Information*

Children's Health Insurance Program (CHIP)Combined Medicaid/CHIPMedicaidPrivateNo InsuranceOther
Insurance Provider*
Primary Care Physician*
Dentist*
Tell us about your child
Does your child have any current or chronic medical conditions? (Ex:asthma, food allergy, special diet, heart problems, seizures, etc.)*

YesNo
If you answered "Yes" to the question above, please list and explain
If you answered yes, would your child require medication during school hours?

YesNo
Does your child have any developmental concerns? (Ex: speech, hearing,vision, autism, injuries, etc.)*

YesNo
If you answered "Yes" to the question above, please list and explain
Does your child have a current Individual Education Plan (IEP)?*

YesNo
Check all that apply to your child and family.*

Behavioral or Social Emotional Concerns (Ex: anger, anxiety, biting, hitting)Domestic Abuse/ViolenceIncarcerated Parent or GuardianLegal documents - Custody, Divorce, Guardianship, Restraining OrderNone of the above
Family Information
Parental Status*

Single FemaleSingle MaleTwo Parent HouseholdNon-ParentGrandparentFosterRelative
Child Lives With*

Both ParentsMotherFatherGrandparentNon-ParentFoster
Custody - if not two parent household*

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

OwnRentPublic HousingPermanent housing shared with familyTemporary HousingTransitional housing, Emergency shelterHomelessOther
Services your family receives (Select all that apply)*

WICSNAPTANFSSIHUDCWSChild SupportNoneOther
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Living Address*

Street Address

Street Address Line 2

CityState / Province

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

MotherFatherGrandparentFosterOther
(A01) Name*

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

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

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

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

YesNo
(A01) Email*
example@example.com
(A01) Date of Birth*

MonthDayYear
Date
(A01) Gender*

MaleFemale
(A01) Race*

WhiteMulti-Racial/Bi-RacialAfrican American or BlackAsianHawaiianPacific IslanderAmerican IndianAlaskan Native
(A01) Ethnicity: Hispanic or Latino*

YesNo
(A01) Current Employment Status*

Full-timePart-timeTrainingSchoolRetiredDisabledSeasonalUnemployedStay at home parentMember 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 lessGrade 10Grade 11Grade 12High School DiplomaGEDVocational SchoolSome CollegeAssociates DegreeBaccalaureate DegreeAdvanced Degree
(A01) Health Information*

QuestPrivateNone
(A01) Insurance Provider*
(A02) Parent/Guardian Information
(A02) Parent/Guardian

MotherFatherGrandparentFosterOther
(A02) Name

First NameLast Name
(A02) Parent/Guardian Home Phone

Area CodePhone Number
(A02) Parent/Guardian Work Phone

Area CodePhone Number
(A02) Parent/Guardian Cell Phone

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

YesNo
(A02) Email
example@example.com
(A02) Date of Birth

MonthDayYear
Date
(A02) Gender

MaleFemale
(A02) Race

WhiteMulti-Racial/Bi-RacialAfrican American or BlackAsianHawaiianPacific IslanderAmerican IndianAlaskan Native
(A02) Ethnicity: Hispanic or Latino

YesNo
(A02) Current Employment Status

Full-timePart-timeTrainingSchoolRetiredDisabledSeasonalUnemployedStay at home parentMember 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 lessGrade 10Grade 11Grade 12High School DiplomaGEDVocational SchoolSome CollegeAssociates DegreeBaccalaureate DegreeAdvanced Degree
(A02) Health Information

QuestPrivateNone
(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 2024-2025

Tell us about your child

Family Information

(A01) Parent/Guardian Information

(A02) Parent/Guardian Information