HELP for Child Care Program Pre-Application Step 1 of 3 33% Children in Your Family Needing Child Care*123Child's Name* First Name* Middle Last Name* Child's Birth Date* MM slash DD slash YYYY Special Needs?* Yes No Special Needs Priority Populations ListIf Special Needs, please indicate all that apply. Children with medically documented special needs Children in long-term foster care who are U.S. citizens or legal permanent residents Children who are adults in protective services Transitioning from homelessness Children of incarcerated parents Minor teenaged birth parents Children affected by natural disaster or loss of home in Hawaii Native Hawaiian or American Indian?* Yes No Immunizations & TB Results Up-to-Date? Yes No 2nd Child's Name* First Name* Middle Last Name* 2nd Child's Birth Date* MM slash DD slash YYYY Special Needs? (2nd Child)* Yes No Special Needs Priority Populations ListIf Special Needs, please indicate all that apply. Children with medically documented special needs Children in long-term foster care who are U.S. citizens or legal permanent residents Children who are adults in protective services Transitioning from homelessness Children of incarcerated parents Minor teenaged birth parents Children affected by natural disaster or loss of home in Hawaii Special Needs Priority Populations ListIf Special Needs, please indicate all that apply. Children with medically documented special needs Children in long-term foster care who are U.S. citizens or legal permanent residents Children who are adults in protective services Transitioning from homelessness Children of incarcerated parents Minor teenaged birth parents Children affected by natural disaster or loss of home in Hawaii Native Hawaiian or American Indian?* Yes No Immunizations & TB Results Up-to-Date? Yes No 3rd Child's Name* First Name* Middle Last Name* 3rd Child's Birth Date* MM slash DD slash YYYY Special Needs? (3rd Child)* Yes No Special Needs Priority Populations ListIf Special Needs, please indicate all that apply. Children with medically documented special needs Children in long-term foster care who are U.S. citizens or legal permanent residents Children who are adults in protective services Transitioning from homelessness Children of incarcerated parents Minor teenaged birth parents Children affected by natural disaster or loss of home in Hawaii Native Hawaiian or American Indian?* Yes No Immunizations & TB Results Up-to-Date? Yes No Parent/Guardian Name* First Last Employment Status* Employed Self-Employed Enrolled in Educational Program or Certified Job Training Unemployed – Actively Looking for Work None of the Above Number Hours per Week Employed*Co-Parent/Guardian Name First Last Co-Parent/Guardian Employment Status Employed Self-Employed Enrolled in Educational Program or Certified Job Training Unemployed – Actively Looking for Work None of the Above Number Hours per Week Employed*Total Number in Your Family*Applicant/Co-Applicant, children needing care, and other minor age children under 18 years old. Estimated Total MONTHLY household income*Total income, before taxes and deductions, from all adults in the family.Total family ASSETS less than $1 million?*Do not include personal cars or home. Yes No Email* Phone*Home Address* Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Mailing Address is Same as Home Address*YesNoMailing Address* Street Address Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code How did you hear about the HELP for Child Care program? Keiki O Ka Aina Program Family or Friend Agency/Child Care Provider Radio/Television Newspaper Keiki O Ka Aina Website Internet Other Name of KOKA ProgramName of Agency/Child Care ProviderWebsiteWhere did you hear about the HELP for Child Care Program?Name of Applicant* First Last Pre-Application Agreement*By checking the box above, I certify that the information I have supplied is true and correct to the best of my knowledge. I understand that to qualify for assistance, I will have to complete a full application form and provide requested documents to prove eligibility. I understand that the information I provide is subject to verification. I agree to the above information.CAPTCHA Δ
