Application Form For Child Care Services
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2STATE OF HAWAII – DEPARTMENT OF HUMAN SERVICES
Benefit, Employment and Support Services Division
APPLICATION FOR CHILD CARE SERVICES
ELIGIBILITY REQUIREMENTS (MUST MEET ALL)
DOCUMENTATION REQUIRED
1.
Child must be under age 13, or 13 through 17,
Copies of birth certificates for all children , baptismal or hospital
and unable to care for self.
certificates, or court decree.
2.
Child must be a US citizen or a Lawful Permanent Resident.
Copies of birth certificates, US passport, Certificate of Naturalization,
Certificate of Citizenship or permanent resident card (“Green Card”).
3.
Child for whom assistance is being requested must
Birth document or other court decree. Applicant
reside with the applicant.
must be a parent (birth, adoptive, foster, hanai) or a legal guardian.
*The provision of a social security number and copies of the social security card for all household members listed on the application is strictly
voluntary. Failure to provide this Information will not affect the application process or the amount of benefits you will receive. The use of social
security numbers will be for agency use only as an internal identifier.
REASON FOR CHILD CARE (CHECK ALL THAT APPLY)
DOCUMENTATION REQUIRED
(PLEASE ATTACH TO COMPLETED APPLICATION)
Parents in Employment, Education or Training.
School enrollment documents which show credits/ hours
enrolled, income verification for the past 2 months,
or if self-employed, current copy of G45 tax form and
General Excise tax license.
Physical or mental incapacity of child, 13 – 17 years old,
Signed statement from a state-licensed physician or
and child is unable to care for self.
psychologist.
Family receives Child Protective Services (CPS).
Child Welfare Services (CWS) Family Service Plan (court ordered).
Parent/legal guardian may lose job because of child
Written warning from employer.
care problems.
Parent/legal guardian has been offered a job
Written proof of job offer.
and will start on ______________________.
PLEASE PRINT
List all family members now living in your home. Please attach a separate sheet if more space is needed.
NAME:
Last
First
M.I.
*Social Security No.
Birth Date
Race
Sex
Marital
(mm/dd/yy)
(Optional)
(M/F)
Status
Applicant
Co-applicant
Residence Address
Home/Cell Phone
Mailing Address
Work Phone
Applicant
Primary Language Spoken
Interpreter Services Needed?
Work Phone
Yes
No
Co-Applicant
*Social Security No.
Race
Birth Date
Sex
Child Care
Name(s) of Child(ren
)
(Optional)
Requested?
(mm/dd/yy)
(M/F)
Child
Yes
No
Child
Yes
No
Child
Yes
No
Child
Yes
No
Child
Yes
No
DHS 911 (10/07)
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