Client Survey

Applying Child's Name:*

First Middle Initial Last

Child's Date Of Birth:*

MM

DD

YYYY

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:*

Child's Health Insurance:*

Medicaid
Private
Military Health
No Health Insurance

Child's Insurance Provider:*

HMSA
Kaiser
Aloha 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:*

Tri-Care

Second Policy/Medical Record Number:*

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 - Father
One Parent - Mother

Are you Currently Homeless?

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:

Guardian 1 Name:*

First Middle Initial Last

Guardian 1 Date of Birth:*

MM

DD

YYYY

Guardian 1 Gender:*

Male
Female

Guardian 1 Ethnicity: Are you Hispanic or Latino Origin?*

Yes
No

Guardian 1 Race:*

Guardian 1 Contact Phone Number:*

Guardian 1 Text Message

Yes
No

Guardian 1 Email Address:

Guardian 1 highest grade completed in school:*

Guardian 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

Guardian 1 Military Status:*

Active
Veteran
N/A

Guardian 1 Relationship to Child:*

Guardian 1 Does the Child Live with you?*

Yes
No
Part Time

Guardian 1 Do you have the same home and mailing address as the child?*

Yes
No

Guardian 1 If No please Provide current address:*

Street Address Address Line 2 City State ZIP Code

Guardian 2 Name:

First Middle Initial Last

Guardian 2 Date of Birth:

MM

DD

YYYY

Guardian 2 Gender:

Male
Female

Guardian 2 Ethnicity: Are you Hispanic or Latino Origin?

Yes
No

Guardian 2 Race:

Guardian 2 Contact Phone Number:

Guardian 2 Text Message

Yes
No

Guardian 2 Email Address:

Guardian 2 highest grade completed in school:

Guardian 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

Guardian 2 Military Status:

Active
Veteran
N/A

Guardian 2 Relationship to Child:

Guardian 2 Does the Child Live with you?

Yes
No
Part Time

Guardian 2 Do you have the same home and mailing address as the child?

Yes
No

Guardian 2 If No please Provide current address:*

Street Address Address Line 2 City State ZIP Code

Estimated Annual Income:*

Number of adults in your family:*

Number of children in your family:*

Other Child 1 Name:

First Middle Initial Last

Other Child 1 Relationship to Applying Child:

Other Child 1 Date of Birth:

MM

DD

YYYY

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:

MM

DD

YYYY

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:

MM

DD

YYYY

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:

MM

DD

YYYY

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:

MM

DD

YYYY

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:

MM

DD

YYYY

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:

MM

DD

YYYY

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:

MM

DD

YYYY

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:

MM

DD

YYYY

Other Child 9 Gender:

Male
Female

How did you hear about us?*

Referring Agency: (Specify)

DOE Referring Agency: (Specify)

Early Intervention Referring Agency: (Specify)

Contact:

Phone #:

Nondiscrimination Statement*

I understand that the information in this application will be held in strict confidence within the agency. I further understand that this is an application for services that are paid for with federal funds and that intentionally providing misleading, inaccurate or untruthful information of a material nature could result in disenrolling my child from Head Start and could have serious legal consequences for me. HCAP does not discriminate on the basis of race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Yes, I agree to Terms and Conditions
No, I do not agree to Terms and Conditions

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Pregnant Woman Application - 2019 - 2020