Contact Us

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
- Prefer not to Respond
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
- Prefer not to Respond
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
- Prefer not to Respond
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
- Prefer not to Respond
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
- Prefer not to Respond
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
- Prefer not to Respond
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
- Prefer not to Respond
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
- Prefer not to Respond
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
- Prefer not to Respond
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
- Prefer not to Respond
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
- Prefer not to Respond
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
- Prefer not to Respond
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
- Prefer not to Respond
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
- Prefer not to Respond
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
- Prefer not to Respond
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
- Prefer not to Respond
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
- Prefer not to Respond

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
Untitled

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: Prenatal Parent
Information about the Prenatal Parent who is applying.
Applying Prenatal Parent Name:*
First Middle Initial Last
Date Of Birth:*
Month
Day
Year
Prenatal Parent Gender:*
- Female
- Prefer Not to Respond
Ethnicity: Is the Applying Prenatal Parent 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:*
Prenatal Parent Type*
- 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 mom.
Adult 1 Name:
First Middle Initial Last
Adult 1 Date of Birth:
Month
Day
Year
Adult 1 Gender:
- Male
- Female
- Prefer Not to Respond
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 Relationship to pregnant mom:
- Biological Parent
- Adoptive Parent
- Step Parent
- Foster Parent
- Grandparent/Relative
Adult 1 Does the pregnant mom live with you?
- Yes
- No
- Part Time
Adult 1 Do you have the same home and mailing address as the pregnant mom?
- 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 mom.
Adult 2 Name:
First Middle Initial Last
Adult 2 Date of Birth:
Month
Day
Year
Adult 2 Gender:
- Male
- Female
- Prefer Not to Respond
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 mom:
- Biological Parent
- Adoptive Parent
- Step Parent
- Foster Parent
- Grandparent/Relative
Adult 2 Does the pregnant mom live with you?
- Yes
- No
- Part Time
Adult 2 Do you have the same home and mailing address as the pregnant mom?
- 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 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 Mom
Other Adult 1 Date of Birth
Month
Day
Year
Other Adult 1 Gender:
- Male
- Female
- Prefer Not to Respond
Other Adult 2 Name:
First Middle Initial Last
Other Adult 2 Relationship to Applying Pregnant Mom
Other Adult 2 Date of Birth
Month
Day
Year
Other Adult 2 Gender:
- Male
- Female
- Prefer Not to Respond
Other Adult 3 Name:
First Middle Initial Last
Other Adult 3 Relationship to Applying Pregnant Mom
Other Adult 3 Date of Birth
Month
Day
Year
Other Adult 3 Gender:
- Male
- Female
- Prefer Not to Respond
Other Adult 1 Name:
First Middle Initial Last
Other Adult 1 Relationship to Applying Pregnant Mom
Other Adult 1 Date of Birth
Month
Day
Year
Other Adult 1 Gender:
- Male
- Female
- Prefer Not to Respond
Other Adult 2 Name:
First Middle Initial Last
Other Adult 2 Relationship to Applying Pregnant Mom
Other Adult 2 Date of Birth
Month
Day
Year
Other Adult 2 Gender:
- Male
- Female
- Prefer Not to Respond
Other Adult 1 Name:
First Middle Initial Last
Other Adult 1 Relationship to Applying Pregnant Mom
Other Adult 1 Date of Birth
Month
Day
Year
Other Adult 1 Gender:
- Male
- Female
- Prefer Not to Respond
Other Adult 2 Name:
First Middle Initial Last
Other Adult 2 Relationship to Applying Pregnant Mom
Other Adult 2 Date of Birth
Month
Day
Year
Other Adult 2 Gender:
- Male
- Female
- Prefer Not to Respond
Other Adult 3 Name:
First Middle Initial Last
Other Adult 3 Relationship to Applying Pregnant Mom
Other Adult 3 Date of Birth
Month
Day
Year
Other Adult 3 Gender:
- Male
- Female
- Prefer Not to Respond
Hidden
Number of children in your family:*

(Use numbers)
Other Child 1 Name:
First Middle Initial Last
Other Child 1 Relationship to Applying pregnant mom:
Other Child 1 Date of Birth:
Month
Day
Year
Other Child 1 Gender:
- Male
- Female
- Prefer Not to Respond
Other Child 2 Name:
First Middle Initial Last
Other Child 2 Relationship to Applying pregnant mom:
Other Child 2 Date of Birth:
Month
Day
Year
Other Child 2 Gender:
- Male
- Female
- Prefer Not to Respond
Other Child 3 Name:
First Middle Initial Last
Other Child 3 Relationship to Applying pregnant mom:
Other Child 3 Date of Birth:
Month
Day
Year
Other Child 3 Gender:
- Male
- Female
- Prefer Not to Respond
Other Child 4 Name:
First Middle Initial Last
Other Child 4 Relationship to Applying pregnant mom:
Other Child 4 Date of Birth:
Month
Day
Year
Other Child 4 Gender:
- Male
- Female
- Prefer Not to Respond
Other Child 5 Name:
First Middle Initial Last
Other Child 5 Relationship to Applying pregnant mom:
Other Child 5 Date of Birth:
Month
Day
Year
Other Child 5 Gender:
- Male
- Female
- Prefer Not to Respond
Other Child 6 Name:
First Middle Initial Last
Other Child 6 Relationship to Applying pregnant mom:
Other Child 6 Date of Birth:
Month
Day
Year
Other Child 6 Gender:
- Male
- Female
- Prefer Not to Respond
Other Child 7 Name:
First Middle Initial Last
Other Child 7 Relationship to Applying pregnant mom:
Other Child 7 Date of Birth:
Month
Day
Year
Other Child 7 Gender:
- Male
- Female
- Prefer Not to Respond
Other Child 8 Name:
First Middle Initial Last
Other Child 8 Relationship to Applying pregnant mom:
Other Child 8 Date of Birth:
Month
Day
Year
Other Child 8 Gender:
- Male
- Female
- Prefer Not to Respond
Other Child 9 Name:
First Middle Initial Last
Other Child 9 Relationship to Applying pregnant mom:
Other Child 9 Date of Birth:
Month
Day
Year
Other Child 9 Gender:
- Male
- Female
- Prefer Not to Respond
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

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More Information

Section 1

Section 2: Child Applicant

Section 3: Family Information

Section 4: Primary Adult

Please, click on next

Section 5: Secondary Adult

Section 6: Other Family Members Supported by Guardian's Income

Certification: Please Read and Submit Your Application

Prenatal Parent Application - 2024

Step 1 of 5

Section 1: How did you hear about us?

Section 2: Prenatal Parent

Section 3: Family Information

Section 4: Primary Adult

Section 5: Secondary Adult

Section 6: Other Family Members Supported by Your or Guardian's Income

CERTIFICATION: Please Read and Submit Your Application