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Chelsea Baxa

Posts by Chelsea Baxa:

HCAP WEEKLY April 21, 2025
HCAP WEEKLY April 7, 2025
HCAP WEEKLY March 24, 2025
HCAP WEEKLY March 10, 2025
HCAP WEEKLY February 17, 2025
HCAP WEEKLY February 3, 2025
HCAP WEEKLY January 27, 2025
HCAP WEEKLY January 20, 2025
HCAP WEEKLY January 13, 2025
HCAP WEEKLY January 6, 2025

1 2 3 … 19 »

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Disclaimer 1: HCAP does not discriminate on the basis of race, color, religion, sex (including pregnancy, sexual orientation, or gender identity), nation orgin, age (40 or older), disability and genetic information (including family medical record), or reprisal or retaliation for civil rights activity in any program or activity conducted.

Disclaimer 2: This website is supported by Grant Number 09CH013096 from the Office of Head Start within the Administration for Children and Families, a division of the U.S. Department of Health and Human Services. Neither the Administration for Children and Families nor any of its components operate, control, are responsible for, or necessarily endorse this website (including, without limitation, its content, technical infrastructure, and policies, and any services or tools provided). The opinions, findings, conclusions, and recommendations expressed are those of Honolulu Community Action Program, Inc. and do not necessarily reflect the views of the Administration for Children and Families and the Office of Head Start.

Copyright © 2025 · All Rights Reserved · Honolulu Community Action Program

1132 Bishop St. Suite 100, Honolulu, HI 96813 · 808-521-4531 · RSS Feed · Log in

Pregnant Women Application - 2025

Pregnant Women apply for HCAP Early Head Start (V. 2025.01.01)

Step 1 of 5

20%

Section 1: How did you hear about us?
How did you hear about us?*
- Early Head Start program
- Family or Friend
- Seen aFlyer
- Seen a Banner
- From an HCAP staff member
- From the HCAP website
- HCAP district office
- From Department of Education
- From another preschool
- From PATCH Website
- From a social media
- Early Intervention
- Received a postcard in the mail
- Attended a Community Fair
- Referring agency
- Other
Referring Agency:
Other:
Contact
Phone Number

Section 2: Pregnant Women
Information about the pregnant women who is applying.
Applying Pregnant Women Name:*
First Middle Initial Last
Date Of Birth:*
Month
Day
Year
Gender:*
- Female
Is the applying pregnant women Hispanic or Latino Origin?*
- Yes
- No
Race:*
- American Indian or Alaskan Native
- Asian
- Black or African American
- Native Hawaiian
- Pacific Islander
- White
- Hispanic/Mexican
- Multi/Bi-Racial
Health Insurance:*
- Medicaid
- Private
- Military Health
- No Health Insurance
Insurance Provider:*
- HMSA
- Kaiser
- Aloha Care
Insurance Provider:*
- HMSA
- Kaiser
- Aloha Care
- UHA
- Tri-Care
Insurance Provider:*
- Tri-Care
Policy/Medical Record Number:*
Does you have a secondary insurance?*
- Yes
- No
Secondary Health Insurance:*
- Medicaid
- Private
- Military Health
Secondary Insurance Provider:*
- HMSA
- Kaiser
- Aloha Care
Secondary Insurance Provider:*
- HMSA
- Kaiser
- Aloha Care
- UHA
- Tri-Care
Secondary Insurance Provider:*
- Tri-Care
Second Policy/Medical Record Number:*
Pregnant Women Age:*
- 18 years old or older
- Under 18 years old
Expected Delivery Date:*
Month
Day
Year
Home Phone Number:
Cell Phone Number:*
Text Message
- Yes
- No
Email
Highest grade completed in school:*
- Less than High School
- High School Graduate
- GED
- Associate's Degree
- Bachelor's Degree
- Master's Degree (or above)
Employment Status: (Check all that apply)*
- Full time Work (35+hrs/wk or more)
- Part Time Work (Under 35 hrs/wk)
- Unemployed
- Training or in School
- Self-Employed
- Seasonally Employed
- Retired or Disabled
- Stay at Home Parent
Military Status:*
- Active
- Veteran
- N/A

Section 3: Family Information
Living Address:*
Street Address Address Line 2 City State ZIP Code
Is your mailing address the same as living address?*
- Yes
- No
Mailing Address:*
Street Address Address Line 2 City State ZIP Code
Parental Status:*
- Two Parents
- One Parent
Are you Currently Homeless?
- Yes - Shelter
- Yes - Vehicle
- Yes - Park/Beach
- Yes - Motel/Hotel
- No
Housing:*
- Own
- Rent
- Public Housing (Section 8, Subsidized, etc.)
- Live with relative/friend
Please check all services your family currently receives:*
- None
- TANF
- Food Stamp/SNAP
- WIC
- Supplemental Security Income (SSI)
- Other
Primary Language:*
Secondary Language:
Section 4: Primary Adult
Information about the primary adult responsible for the applying pregnant women.
Adult 1 Name:
First Middle Initial Last
Adult 1 Date of Birth:
Month
Day
Year
Adult 1 Gender:
- Male
- Female
Adult 1: Are you Hispanic or Latino Origin?
- Yes
- No
Adult 1 Race:
- American Indian or Alaskan Native
- Asian
- Black or African American
- Native Hawaiian
- Pacific Islander
- White
- Hispanic/Mexican
- Multi/Bi-Racial
Adult 1 Home Phone Number:
Adult 1 Cell Phone Number:
Adult 1 Text Message
- Yes
- No
Adult 1 Email Address:
Adult 1 Relationship to pregnant women:
- Biological Parent
- Adoptive Parent
- Step Parent
- Foster Parent
- Grandparent/Relative
Adult 1 Does the pregnant women live with you?
- Yes
- No
- Part Time
Adult 1: Do you have the same home and mailing address as the pregnant women?
- Yes
- No
Adult 1 If No please provide current address:
Street Address Address Line 2 City State ZIP Code
Adult 1 highest grade completed in school:
- Less than High School
- High School Graduate
- GED
- Associate's Degree
- Bachelor's Degree
- Master's Degree (or above)
Adult 1 Employment Status: (Check all that apply)
- Full time Work (35+hrs/wk or more)
- Part Time Work (Under 35 hrs/wk)
- Unemployed
- Training or in School
- Self-Employed
- Seasonally Employed
- Retired or Disabled
- Stay at Home Parent
Adult 1 Military Status:
- Active
- Veteran
- N/A
Section 5: Secondary Adult
Information about the secondary adult responsible for applying pregnant women.
Adult 2 Name:
First Middle Initial Last
Adult 2 Date of Birth:
Month
Day
Year
Adult 2 Gender:
- Male
- Female
Adult 2 Ethnicity: Are you Hispanic or Latino Origin?
- Yes
- No
Adult 2 Race:
- American Indian or Alaskan Native
- Asian
- Black or African American
- Native Hawaiian
- Pacific Islander
- White
- Hispanic/Mexican
- Multi/Bi-Racial
Adult 2 Home Phone Number:
Adult 2 Cell Phone Number:
Adult 2 Text Message
- Yes
- No
Adult 2: Email Address:
Adult 2 Relationship to pregnant women:
- Biological Parent
- Adoptive Parent
- Step Parent
- Foster Parent
- Grandparent/Relative
Adult 2 Does the pregnant women live with you?
- Yes
- No
- Part Time
Adult 2, do you have the same home and mailing address as the pregnant women?
- Yes
- No
If No please provide current address:
Street Address Address Line 2 City State ZIP Code
Adult 2 highest grade completed in school:
- Less than High School
- High School Graduate
- GED
- Associate's Degree
- Bachelor's Degree
- Master's Degree (or above)
Adult 2 Employment Status: (Check all that apply)
- Full time Work (35+hrs/wk or more)
- Part Time Work (Under 35 hrs/wk)
- Unemployed
- Training or in School
- Seasonally Employed
- Self-Employed
- Retired or Disabled
- Stay at Home Parent
Adult 2 Military Status:
- Active
- Veteran
- N/A

Section 6: Other Family Members Supported by Your or Guardian's Income
Estimated Annual Income:*
Number of adults in your family:*

(Use numbers)
Other Adult 1 Name:
First Middle Initial Last
Other Adult 1 Relationship to Applying Pregnant Women:
Other Adult 1 Date of Birth
Month
Day
Year
Other Adult 1 Gender:
- Male
- Female
Other Adult 2 Name:
First Middle Initial Last
Other Adult 2 Relationship to Applying Pregnant Women:
Other Adult 2 Date of Birth
Month
Day
Year
Other Adult 2 Gender:
- Male
- Female
Other Adult 3 Name:
First Middle Initial Last
Other Adult 3 Relationship to Applying Pregnant Women:
Other Adult 3 Date of Birth
Month
Day
Year
Other Adult 3 Gender:
- Male
- Female
Other Adult 1 Name:
First Middle Initial Last
Other Adult 1 Relationship to Applying Pregnant Women:
Other Adult 1 Date of Birth
Month
Day
Year
Other Adult 1 Gender:
- Male
- Female
Other Adult 2 Name:
First Middle Initial Last
Other Adult 2 Relationship to Applying Pregnant Women
Other Adult 2 Date of Birth
Month
Day
Year
Other Adult 2 Gender:
- Male
- Female
Other Adult 1 Name:
First Middle Initial Last
Other Adult 1 Relationship to Applying Pregnant Women:
Other Adult 1 Date of Birth
Month
Day
Year
Other Adult 1 Gender:
- Male
- Female
Other Adult 2 Name:
First Middle Initial Last
Other Adult 2 Relationship to Applying Pregnant Women:
Other Adult 2 Date of Birth
Month
Day
Year
Other Adult 2 Gender:
- Male
- Female
Other Adult 3 Name:
First Middle Initial Last
Other Adult 3 Relationship to Applying Pregnant Women:
Other Adult 3 Date of Birth
Month
Day
Year
Other Adult 3 Gender:
- Male
- Female
Hidden
Number of children in your family:*

(Use numbers)
Other Child 1 Name:
First Middle Initial Last
Other Child 1 Relationship to Applying Pregnant Women:
Other Child 1 Date of Birth:
Month
Day
Year
Other Child 1 Gender:
- Male
- Female
Other Child 2 Name:
First Middle Initial Last
Other Child 2 Relationship to Applying Pregnant Women:
Other Child 2 Date of Birth:
Month
Day
Year
Other Child 2 Gender:
- Male
- Female
Other Child 3 Name:
First Middle Initial Last
Other Child 3 Relationship to Applying Pregnant Women:
Other Child 3 Date of Birth:
Month
Day
Year
Other Child 3 Gender:
- Male
- Female
Other Child 4 Name:
First Middle Initial Last
Other Child 4 Relationship to Applying pregnant Women:
Other Child 4 Date of Birth:
Month
Day
Year
Other Child 4 Gender:
- Male
- Female
Other Child 5 Name:
First Middle Initial Last
Other Child 5 Relationship to Applying pregnant Women:
Other Child 5 Date of Birth:
Month
Day
Year
Other Child 5 Gender:
- Male
- Female
Other Child 6 Name:
First Middle Initial Last
Other Child 6 Relationship to Applying pregnant Women:
Other Child 6 Date of Birth:
Month
Day
Year
Other Child 6 Gender:
- Male
- Female
Other Child 7 Name:
First Middle Initial Last
Other Child 7 Relationship to Applying pregnant Women:
Other Child 7 Date of Birth:
Month
Day
Year
Other Child 7 Gender:
- Male
- Female
Other Child 8 Name:
First Middle Initial Last
Other Child 8 Relationship to Applying Pregnant Women:
Other Child 8 Date of Birth:
Month
Day
Year
Other Child 8 Gender:
- Male
- Female
Other Child 9 Name:
First Middle Initial Last
Other Child 9 Relationship to Applying Pregnant Women:
Other Child 9 Date of Birth:
Month
Day
Year
Other Child 9 Gender:
- Male
- Female
Referring Agency: (Specify)
Contact:
Phone #:
Hidden
Early Intervention Referring Agency: (Specify)
Hidden
Contact:
Hidden
Phone #:

CERTIFICATION: Please Read and Submit Your Application
Nondiscrimination Statement*
I certify that the information provided herein, and in any other related documents and/or representations, are true and correct to the best of my knowledge, and I understand that access to any and all HCAP premises, programs and/or services through misrepresentation or fraud may be punishable under HCAP policies, procedures, or practices including, but not limited to, refusal of services, at the sole discretion of HCAP. I further understand that a false statement under these forms or other communications can also expose me to civil and/or criminal liability that may include financial obligations or criminal penalties. I understand that this information will be used only to determine if I may gain entry onto any and all HCAP premises, and/or to determine if I and my family are eligible for any and all HCAP services, and will not be released to non-HCAP sources without my prior knowledge and written consent. HCAP does not discriminate on the basis of race, color, religion, sex (including pregnancy, sexual orientation, or gender identity), national origin, age (40 or older), disability and genetic information (including family medical history), or reprisal or retaliation for prior civil rights activity in any program or activity conducted.
- Yes, I agree to Terms and Conditions
- No, I do not agree to Terms and Conditions

Employment Application - v2024

Step 1 of 7

14%

✦Personal Information✦
Application Date(Required)
MM slash DD slash YYYY
Position Applied for(Required)
Name(Required)
First Middle Last
Address(Required)
Street Address Address Line 2 City State ZIP Code
Last Four Digits of Social Security Number(Required)
Best Contact Number(Required)
Email(Required)
Are you legally authorized to work in the United States?(Required)
- Yes
- No
If required by the position, do you have a valid driver’s license?(Required)
- Yes
- No
Does your automobile meet all license/insurance requirements?(Required)
- Yes
- No
Do you have daily access to this automobile?(Required)
- Yes
- No

✦Employment Experience✦
Most recent employer 1
May we call this employer?
- Yes
- No
Employer Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number
Dates Employed
Employment Type / Status
- Part Time
- Full Time
Your Job Title
Your Duties
Supervisor's Name
Reason for Leaving
Employer 2
May we call this employer?
- Yes
- No
Employer Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number
Dates Employed
Employment Type / Status
- Part Time
- Full Time
Your Job Title
Your Duties
Supervisor's Name
Reason for Leaving
Employer 3
May we call this employer?
- Yes
- No
Employer Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number
Dates Employed
Employment Type / Status
- Part Time
- Full Time
Your Job Title
Your Duties
Supervisor's Name
Reason for Leaving
Employer 4
May we call this employer?
- Yes
- No
Employer Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number
Dates Employed
Employment Type / Status
- Part Time
- Full Time
Your Job Title
Your Duties
Supervisor's Name
Reason for Leaving

✦Education✦
High School
High School Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Diploma
- Yes
- No
College/University
College/University Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Degree
- Yes
- No
List Degree(s) Obtained – Major
Graduate School:
Graduate School Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Graduate Degree
- Yes
- No
List Degree(s) Obtained – Major
List any additional information concerning educational accomplishments you feel may be helpful to us in considering your application.

✦Military Service✦
Active Duty Dates(Required)
- No Service
- In Service
Service Dates
Branch of Service
Current Reserve Status
- Active
- Inactive
Type of Discharge / Date
Military School, Studies, and/or Experience

✦General Information✦
Specify type of work you are interested in
Do you have any preference as to work location or travel?(Required)
- Yes
- No
If “Yes”, please explain
List business machines or equipment you can operate
List computer programs you can operate
Date available for employment(Required)
MM slash DD slash YYYY
Salary expected
What type of employment would you be willing to accept?(Required)
- Full Time
- Part Time
- Temporary (To 3 months)
- Temporary (More than 3 months)
- Substitute, on call
Do you have any friends employed by HCAP?(Required)
- Yes
- No
If Yes, name and program
Do you have any relatives employed by HCAP?(Required)
- Yes
- No
If Yes, name and program
Have you previously applied for a position or been employed by HCAP?(Required)
- Yes
- No
If yes, give date and position
How did you hear about this position?
Are you an HCAP Board Member, District Council Member or Head Start Policy Council Member?(Required)
- Yes
- No
Please give any further information which may be helpful to us in considering your qualifications. List any community work experience or volunteer experience.
You are not required to list activities which may reveal your race, religion or national origin.

✦Activities✦
List scholastic honors and activities with offices held
List hobbies and outside activities (including civic activities, membership in professional organizations)
✦Reference✦
(Give 3 professional references of persons who are qualified to answer questions regarding your current/former employment and/or your qualifications for the position you are seeking.)
Name 1
First Last
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name 2
First Last
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name 3
First Last
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Nondiscrimination Statement(Required)
As part of our employment procedures, a routine inquiry may be made to obtain applicable information concerning your character, general reputation, and personal characteristics. It is the policy of this Company to hire only U.S. Citizens and aliens who are authorized to work in this country. (As a condition of employment, you will be required to produce original documents establishing your identity and authorization to work, and to complete the U.S. Immigration and Naturalization Service’s Form I-9.) I certify that all statements made on this application are true and complete to the best of my knowledge. I understand that my application will not be considered if it is incomplete. Further, I understand that any misrepresentation or omission when discovered, will subject me to discharge, and I hereby authorize any investigation of the above or related work experience, education, or reputation information for purposes of consideration of my application for employment. This application is not a contract and cannot create a contract. I understand that if I am employed, my employment is “at will” and can be terminated at any time, either by myself or the Company, with or without cause or reason and with or without notice.
- Yes, I agree to Terms and Conditions
- No, I do not agree to Terms and Conditions
Signature(Required)
Please type your full name.
Date(Required)
MM slash DD slash YYYY

Early Head Start and Head Start Application - 2025

Apply your child for HCAP Early Head Start and Head Start (V. 2025.01.01)

Step 1 of 7

14%

Section 1
How did you hear about us?*
- Early Head Start program
- Family or Friend
- Seen aFlyer
- Seen a Banner
- From an HCAP staff member
- From the HCAP website
- HCAP district office
- From Department of Education
- From another preschool
- From PATCH Website
- From a social media
- Early Intervention
- Received a postcard in the mail
- Attended a Community Fair
- Referring agency
- Other
Other (if you check "Other" on previous question):
Referring agency name: (if you check "Referring agency" on previous question):
Contact:
Phone #:

Section 2: Child Applicant
Information about the child who is applying.
Applying Child's Name:*
First Middle Initial Last
Child's Date Of Birth:*
Month
Day
Year
Child's Gender:*
- Male
- Female
Is the Applying Child a Foster Child?*
- Yes
- No
Ethnicity: Is the Applying Child Hispanic or Latino Origin?*
- Yes
- No
Child's Race:*
- American Indian or Alaskan Native
- Asian
- Black or African American
- Native Hawaiian
- Pacific Islander
- White
- Bi-Racial/Multi
Child's Health Insurance:*
- Medicaid
- Private
- Military Health
- No Health Insurance
Child's Insurance Provider:*
- HMSA
- Kaiser
- Aloha Care
Child's Insurance Provider:*
- HMSA
- Kaiser
- Aloha Care
- UHA
- Tri-Care
Child's Insurance Provider:*
- Tri-Care
Policy/Medical Record Number:*
Does your child have a secondary insurance?*
- Yes
- No
Child's Secondary Health Insurance:*
- Medicaid
- Private
- Military Health
Child's Secondary Insurance Provider:*
- HMSA
- Kaiser
- Aloha Care
Child's Secondary Insurance Provider:*
- HMSA
- Kaiser
- Aloha Care
- UHA
- Tri-Care
Child's Secondary Insurance Provider:*
- Tri-Care
Second Policy/Medical Record Number:*

Section 3: Family Information
Living Address:*
Street Address Address Line 2 City State ZIP Code
Is your Mailing Address the same as living Address?*
- Yes
- No
Mailing Address:*
Street Address Address Line 2 City State ZIP Code
Parental Status:*
- Two Parents
- One Parent
Are you Currently Homeless?*
- Yes - Shelter
- Yes - Vehicle
- Yes - Park/Beach
- Yes - Motel/Hotel
- No
Housing:*
- Own
- Rent
- Public Housing (Section 8, Subsidized, etc.)
- Live with relative/friend
Has your child been identified by a PROFESSIONAL as having a disability or special need?*
- Yes
- No
If YES, please explain:*
Please check all services your family currently receives:*
- None
- TANF
- Food Stamp/SNAP
- WIC
- Child Welfare Services (open case)
- Supplemental Security Income (SSI)
- Other
Child's Primary Language:*
Child's Secondary Language:

Section 4: Primary Adult
Information about the primary adult responsible for applying child.
Adult 1 Name:*
First Middle Initial Last
Adult 1 Date of Birth:*
Month
Day
Year
Adult 1 Gender:*
- Male
- Female
Adult 1 Ethnicity: Are you Hispanic or Latino Origin?*
- Yes
- No
Adult 1 Race:*
- American Indian or Alaskan Native
- Asian
- Black or African American
- Native Hawaiian
- Pacific Islander
- White
- Hispanic/Mexican
- Multi/Bi-Racial
Adult 1 Home Phone Number:
Adult 1 Cell Phone Number:
Adult 1 Text Message
- Yes
- No
Adult 1 Email Address:
Adult 1 Email Address:*
Adult 1 Relationship to Child:*
- Biological Parent
- Adoptive Parent
- Step Parent
- Foster Parent
- Grandparent/Relative
Adult 1 Does the Child Live with you?*
- Yes
- No
- Part Time
Adult 1 Do you have the same home and mailing address as the child?*
- Yes
- No
Adult 1 If No please Provide current address:*
Street Address Address Line 2 City State ZIP Code
Adult 1 highest grade completed in school:*
- Less than High School
- High School Graduate
- GED
- Associate's Degree
- Bachelor's Degree
- Master's Degree (or above)
Adult 1 Employment Status: (Check all that apply)*
- Full time Work (35+hrs/wk or more)
- Part Time Work (Under 35 hrs/wk)
- Unemployed
- Training or in School
- Self-Employed
- Seasonally Employed
- Retired or Disabled
- Stay at Home Parent
Adult 1 Military Status:*
- Active
- Veteran
- N/A

Please, click on next
Section 5: Secondary Adult
Information about the secondary adult responsible for applying child.
Adult 2 Name:
First Middle Initial Last
Adult 2 Date of Birth:
Month
Day
Year
Adult 2 Gender:
- Male
- Female
Adult 2 Ethnicity: Are you Hispanic or Latino Origin?
- Yes
- No
Adult 2 Race:
- American Indian or Alaskan Native
- Asian
- Black or African American
- Native Hawaiian
- Pacific Islander
- White
- Hispanic/Mexican
- Multi/Bi-Racial
Adult 2 Home Phone Number:
Adult 2 Cell Phone Number:
Adult 2 Text Message
- Yes
- No
Adult 2 Email Address:
Adult 2 Relationship to Child:
- Biological Parent
- Adoptive Parent
- Step Parent
- Foster Parent
- Grandparent/Relative
Adult 2 Does the Child Live with you?
- Yes
- No
- Part Time
Adult 2 Do you have the same home and mailing address as the child?
- Yes
- No
Adult 2 If No please Provide current address:
Street Address Address Line 2 City State ZIP Code
Adult 2 highest grade completed in school:
- Less than High School
- High School Graduate
- GED
- Associate's Degree
- Bachelor's Degree
- Master's Degree (or above)
Adult 2 Employment Status: (Check all that apply)
- Full time Work (35+hrs/wk or more)
- Part Time Work (Under 35 hrs/wk)
- Unemployed
- Training or in School
- Seasonally Employed
- Self-Employed
- Retired or Disabled
- Stay at Home Parent
Adult 2 Military Status:
- Active
- Veteran
- N/A

Section 6: Other Family Members Supported by Guardian's Income
Estimated Annual Income:*
Number of adults in your family:*

(Use Numbers)
Other Adult 1 Name:
First Middle Initial Last
Other Adult 1 Relationship to Applying Child:
Other Adult 1 Date of Birth:
Month
Day
Year
Other Adult 1 Gender:
- Male
- Female
Other Adult 2 Name:
First Middle Initial Last
Other Adult 2 Relationship to Applying Child:
Other Adult 2 Date of Birth:
Month
Day
Year
Other Adult 2 Gender:
- Male
- Female
Other Adult 1 Name:
First Middle Initial Last
Other Adult 1 Relationship to Applying Child:
Other Adult 1 Date of Birth:
Month
Day
Year
Other Adult 1 Gender:
- Male
- Female
Other Adult 2 Name:
First Middle Initial Last
Other Adult 2 Relationship to Applying Child:
Other Adult 2 Date of Birth:
Month
Day
Year
Other Adult 2 Gender:
- Male
- Female
Other Adult 3 Name:
First Middle Initial Last
Other Adult 3 Relationship to Applying Child:
Other Adult 3 Date of Birth:
Month
Day
Year
Other Adult 3 Gender:
- Male
- Female
Hidden
Number of children in your family:*

(Use Numbers)
Other Child 1 Name:
First Middle Initial Last
Other Child 1 Relationship to Applying Child:
Other Child 1 Date of Birth:
Month
Day
Year
Other Child 1 Gender:
- Male
- Female
Other Child 2 Name:
First Middle Initial Last
Other Child 2 Relationship to Applying Child:
Other Child 2 Date of Birth:
Month
Day
Year
Other Child 2 Gender:
- Male
- Female
Other Child 3 Name:
First Middle Initial Last
Other Child 3 Relationship to Applying Child:
Other Child 3 Date of Birth:
Month
Day
Year
Other Child 3 Gender:
- Male
- Female
Other Child 4 Name:
First Middle Initial Last
Other Child 4 Relationship to Applying Child:
Other Child 4 Date of Birth:
Month
Day
Year
Other Child 4 Gender:
- Male
- Female
Other Child 5 Name:
First Middle Initial Last
Other Child 5 Relationship to Applying Child:
Other Child 5 Date of Birth:
Month
Day
Year
Other Child 5 Gender:
- Male
- Female
Other Child 6 Name:
First Middle Initial Last
Other Child 6 Relationship to Applying Child:
Other Child 6 Date of Birth:
Month
Day
Year
Other Child 6 Gender:
- Male
- Female
Other Child 7 Name:
First Middle Initial Last
Other Child 7 Relationship to Applying Child:
Other Child 7 Date of Birth:
Month
Day
Year
Other Child 7 Gender:
- Male
- Female
Other Child 8 Name:
First Middle Initial Last
Other Child 8 Relationship to Applying Child:
Other Child 8 Date of Birth:
Month
Day
Year
Other Child 8 Gender:
- Male
- Female
Other Child 9 Name:
First Middle Initial Last
Other Child 9 Relationship to Applying Child:
Other Child 9 Date of Birth:
Month
Day
Year
Other Child 9 Gender:
- Male
- Female

Certification: Please Read and Submit Your Application
Nondiscrimination Statement*
I certify that the information provided herein, and in any other related documents and/or representations, are true and correct to the best of my knowledge, and I understand that access to any and all HCAP premises, programs and/or services through misrepresentation or fraud may be punishable under HCAP policies, procedures, or practices including, but not limited to, refusal of services, at the sole discretion of HCAP. I further understand that a false statement under these forms or other communications can also expose me to civil and/or criminal liability that may include financial obligations or criminal penalties. I understand that this information will be used only to determine if I may gain entry onto any and all HCAP premises, and/or to determine if I and my family are eligible for any and all HCAP services, and will not be released to non-HCAP sources without my prior knowledge and written consent. HCAP does not discriminate on the basis of race, color, religion, sex (including pregnancy, sexual orientation, or gender identity), national origin, age (40 or older), disability and genetic information (including family medical history), or reprisal or retaliation for prior civil rights activity in any program or activity conducted.
- Yes, I agree to Terms and Conditions
- No, I do not agree to Terms and Conditions
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