HELP for Childcare: Pre-Application

Applicant (Parent) Name:*

First NameLast Name

Co-Applicant (Co-Parent) Name:

First NameLast Name

Number of children needing childcare:*

Child #1 Name:*

First NameLast Name

Child #1 Date of Birth:*

Date

Families with Special Needs include:

child with medically-documented special needs
children in long-term foster care who are U.S. citizens or legal permanent residents
children in care of adults in protective services
transitioning from homelessness
children of incarcerated parents
child of minor teenaged birth parents
child affected by natural disaster or loss of home in Hawaii

Do any of the situations listed above apply to Child #1?*

YesNo

Does Child #1 possess Native Hawaiian, American Indian, or Alaska Native ancestry?*

YesNo

Child #2 Name:

First NameLast Name

Child #2 Date of Birth:

Date

Families with Special Needs include:

child with medically-documented special needs
children in long-term foster care who are U.S. citizens or legal permanent residents
children in care of adults in protective services
transitioning from homelessness
children of incarcerated parents
child of minor teenaged birth parents
child affected by natural disaster or loss of home in Hawaii

Do any of the situations listed above apply to Child #2?

YesNo

Does Child #2 possess Native Hawaiian, American Indian, or Alaska Native ancestry?

YesNo

Child #3 Name:

First NameLast Name

Child #3 Date of Birth:

Date

Families with Special Needs include:

child with medically-documented special needs
children in long-term foster care who are U.S. citizens or legal permanent residents
children in care of adults in protective services
transitioning from homelessness
children of incarcerated parents
child of minor teenaged birth parents
child affected by natural disaster or loss of home in Hawaii

Do any of the situations listed above apply to Child #3?

YesNo

Does Child #3 possess Native Hawaiian, American Indian, or Alaska Native ancestry?

YesNo

Child #1