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Early Head Start and Head Start Application - 2023
Apply your child for HCAP Early Head Start and Head Start (V. 2021.01.01)
Section A: Child Applicant
Information about the child who is applying.
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:
*
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 B: Family Information
Living Address:
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Is your Mailing Address the same as living Address?
*
Yes
No
Mailing Address:
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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 C: Primary Adult
Information about the primary adult responsible for applying child.
Adult 1 Name:
*
First
Middle Initial
Last
Adult 1 Date of Birth:
*
MM
DD
YYYY
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Adult 1 highest grade completed in school:
*
Grade 9 or less
Grade 10
Grade 11
High School Graduate
GED
Training Certificate
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 D: Secondary Adult
Information about the secondary adult responsible for applying child.
Adult 2 Name:
First
Middle Initial
Last
Adult 2 Date of Birth:
MM
DD
YYYY
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Adult 2 highest grade completed in school:
Grade 9 or less
Grade 10
Grade 11
High School Graduate
GED
Training Certificate
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 E: 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:
MM
DD
YYYY
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:
MM
DD
YYYY
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:
MM
DD
YYYY
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:
MM
DD
YYYY
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:
MM
DD
YYYY
Other Adult 3 Gender:
Male
Female
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:
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
Section F
How did you hear about us?
*
Early Head Start
Family or Friend
Flyers
HCAP Staff
HCAP Website
Social Media
Walk-In
DOE
Early Intervention
Agency Referal
Other
Referring Agency: (Specify)
Contact:
Phone #:
DOE Referring Agency: (Specify)
Contact:
Phone #:
Early Intervention Referring Agency: (Specify)
Contact:
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
X
Pregnant Woman Application - 2023
Pregnant woman apply for HCAP Early Head Start (V. 2021.01.01)
Section A: Prenatal Mom
Information about the pregnant mom who is applying.
Applying Pregnant woman Name:
*
First
Middle Initial
Last
Date Of Birth:
*
MM
DD
YYYY
Ethnicity: Is the Applying Pregnant Woman 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 Woman Type
*
18 years old or older
Under 18 years old
Expected Delivery Date:
*
MM
DD
YYYY
Home Phone Number:
Cell Phone Number:
*
Text Message
Yes
No
Email
Highest grade completed in school:
*
Grade 9 or less
Grade 10
Grade 11
High School Graduate
GED
Training Certificate
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 B: Family Information
Living Address:
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Is your Mailing Address the same as living Address?
*
Yes
No
Mailing Address:
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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 C: 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:
MM
DD
YYYY
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 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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Adult 1 highest grade completed in school:
Grade 9 or less
Grade 10
Grade 11
High School Graduate
GED
Training Certificate
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 D: Secondary Adult
Information about the secondary adult responsible for applying pregnant mom.
Adult 2 Name:
First
Middle Initial
Last
Adult 2 Date of Birth:
MM
DD
YYYY
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 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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Adult 2 highest grade completed in school:
Grade 9 or less
Grade 10
Grade 11
High School Graduate
GED
Training Certificate
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 E: 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
MM
DD
YYYY
Other Adult 1 Gender:
Male
Female
Other Adult 2 Name:
First
Middle Initial
Last
Other Adult 2 Relationship to Applying Pregnant Mom
Other Adult 2 Date of Birth
MM
DD
YYYY
Other Adult 2 Gender:
Male
Female
Other Adult 3 Name:
First
Middle Initial
Last
Other Adult 3 Relationship to Applying Pregnant Mom
Other Adult 3 Date of Birth
MM
DD
YYYY
Other Adult 3 Gender:
Male
Female
Other Adult 1 Name:
First
Middle Initial
Last
Other Adult 1 Relationship to Applying Pregnant Mom
Other Adult 1 Date of Birth
MM
DD
YYYY
Other Adult 1 Gender:
Male
Female
Other Adult 2 Name:
First
Middle Initial
Last
Other Adult 2 Relationship to Applying Pregnant Mom
Other Adult 2 Date of Birth
MM
DD
YYYY
Other Adult 2 Gender:
Male
Female
Other Adult 1 Name:
First
Middle Initial
Last
Other Adult 1 Relationship to Applying Pregnant Mom
Other Adult 1 Date of Birth
MM
DD
YYYY
Other Adult 1 Gender:
Male
Female
Other Adult 2 Name:
First
Middle Initial
Last
Other Adult 2 Relationship to Applying Pregnant Mom
Other Adult 2 Date of Birth
MM
DD
YYYY
Other Adult 2 Gender:
Male
Female
Other Adult 3 Name:
First
Middle Initial
Last
Other Adult 3 Relationship to Applying Pregnant Mom
Other Adult 3 Date of Birth
MM
DD
YYYY
Other Adult 3 Gender:
Male
Female
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:
MM
DD
YYYY
Other Child 1 Gender:
Male
Female
Other Child 2 Name:
First
Middle Initial
Last
Other Child 2 Relationship to Applying pregnant mom:
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 pregnant mom:
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 pregnant mom:
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 pregnant mom:
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 pregnant mom:
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 pregnant mom:
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 pregnant mom:
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 pregnant mom:
Other Child 9 Date of Birth:
MM
DD
YYYY
Other Child 9 Gender:
Male
Female
Section F
How did you hear about us?
*
Early Head Start
Family or Friend
Flyers
HCAP Staff
HCAP Website
Social Media
Walk-In
DOE
Early Intervention
Agency Referral
Other
Referring Agency: (Specify)
Contact:
Phone #:
DOE Referring Agency: (Specify)
Contact:
Phone #:
Early Intervention Referring Agency: (Specify)
Contact:
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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