Thank you for your interest in the Maui Family Support Services, Inc. Early Head Start Progra. Please complete this form to begin the application process. All fields marked with a * are required. Incomplete applications CANNOT BE PROCESSED and will be delayed.
Parent/Guardian
First Name (Required)
Last Name (Required)
Birthday (Required)
Gender
Female
Male
Email Address (Required)
Confirm Email Address
It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.
Mobile Phone
Opt In for Text Messages
Yes
No
Home Phone
Work Phone
Ext.
It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.
Race (Required)
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Hispanic (Required)
Yes
No
Lives with Family
Yes
No
English Proficiency (Required)
Little
Moderate
None
Proficient
Other Language (Required)
African Languages
American Sign Language
Carribean Languages
East Asian Languages (Filipino)
English
European & Slavic Languages (French, German)
Middle Eastern & South Asian Languages
Native American/Alaska Native Languages
Other Languages (Please Specify)
Pacific Island Languages (Chuukese)
Pacific Island Languages (Hawaiian)
Pacific Island Languages (Kosraean)
Pacific Island Languages (Marshallese)
Pacific Island Languages (Pohnpeian)
Pacific Island Languages (Samoan)
Pacific Island Languages (Tongan)
Spanish
Spanish (Mexican, Central American, etc)
Other Language Proficiency (Required)
Little
Moderate
None
Proficient
Highest Grade Completed (Required)
Associate's Degree
Bachelor's Degree
College Degree/Training Cert.
College or Advance Training
General Education Diploma
Grade 10
Grade 11
Grade 12
Grade 9 or less
High School Graduate
Master's Degree
Employment Status (Required)
Full-time & Training
Full-time (35 hours/week or more)
Part-time & Training
Part-time (Under 35 hours/week)
Retired or Disabled
Seasonally Employed
Training or School
Unemployed
Child's Relationship (Required)
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Provides Financial Support
Yes
No
Teen Parent
Yes
No
Address
Is your family experiencing homelessness?
Yes
No
Living Address (Required)
Address Line 2
City (Required)
State (Required)
ZIP (Required)
Click here
to find a provider in your area.
Mailing Address same as Living Address
Mailing Address
Address Line 2
City
State
ZIP
Additional Parent/Guardian
Is there another parent/guardian in the family?
Yes
No
First Name (Required)
Last Name (Required)
Birthday (Required)
Gender (Required)
Female
Male
Email Address
Confirm Email Address
It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.
Mobile Phone
Opt In for Text Messages
Yes
No
Home Phone
Work Phone
Ext.
It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.
Race (Required)
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Hispanic (Required)
Yes
No
Lives with Family
Yes
No
English Proficiency (Required)
Little
Moderate
None
Proficient
Other Language (Required)
African Languages
American Sign Language
Carribean Languages
East Asian Languages (Filipino)
English
European & Slavic Languages (French, German)
Middle Eastern & South Asian Languages
Native American/Alaska Native Languages
Other Languages (Please Specify)
Pacific Island Languages (Chuukese)
Pacific Island Languages (Hawaiian)
Pacific Island Languages (Kosraean)
Pacific Island Languages (Marshallese)
Pacific Island Languages (Pohnpeian)
Pacific Island Languages (Samoan)
Pacific Island Languages (Tongan)
Spanish
Spanish (Mexican, Central American, etc)
Other Language Proficiency (Required)
Little
Moderate
None
Proficient
Highest Grade Completed (Required)
Associate's Degree
Bachelor's Degree
College Degree/Training Cert.
College or Advance Training
General Education Diploma
Grade 10
Grade 11
Grade 12
Grade 9 or less
High School Graduate
Master's Degree
Employment Status (Required)
Full-time & Training
Full-time (35 hours/week or more)
Part-time & Training
Part-time (Under 35 hours/week)
Retired or Disabled
Seasonally Employed
Training or School
Unemployed
Child's Relationship (Required)
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Provides Financial Support
Yes
No
Teen Parent
Yes
No
Family Information
Number of Parents/Guardians (Required)
One Parent Family
Two Parent Family
Relationship to Participant(s) (Required)
Foster parent(s) not including relatives
Grandparent(s)
Other
Parent(s) (e.g. biological, adoptive, stepparents)
Relative(s) other than grandparents
Primary Language at Home (Required)
African Languages
American Sign Language
Carribean Languages
East Asian Languages (Filipino)
English
European & Slavic Languages (French, German)
Middle Eastern & South Asian Languages
Native American/Alaska Native Languages
Other Languages (Please Specify)
Pacific Island Languages (Chuukese)
Pacific Island Languages (Hawaiian)
Pacific Island Languages (Kosraean)
Pacific Island Languages (Marshallese)
Pacific Island Languages (Pohnpeian)
Pacific Island Languages (Samoan)
Pacific Island Languages (Tongan)
Spanish
Spanish (Mexican, Central American, etc)
Is another language being acquired or learned at home? (Required)
Yes
No
Number in Household (Required)
Number in Family (Required)
Gross Annual Income
Is your family receiving cash benefits or other services under the Temporary Assistance for Needy Families (TANF) program?
Yes
No
Is your family receiving Supplemental Security Income (SSI)?
Yes
No
Is your family receiving services from WIC?
Yes
No
Is your family receiving services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps?
Yes
No
Is at least one parent/guardian an active duty member of the United States military?
Yes
No
Is at least one parent/guardian a veteran of the United States military?
Yes
No
Emergency Contacts
Add Emergency Contact
Child (Applicant)
First Name (Required)
Last Name (Required)
Nickname
Birthday (Required)
Gender (Required)
Female
Male
Race (Required)
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Hispanic (Required)
Yes
No
English Proficiency (Required)
Little
Moderate
None
Proficient
Other Language
African Languages
American Sign Language
Carribean Languages
East Asian Languages (Filipino)
English
European & Slavic Languages (French, German)
Middle Eastern & South Asian Languages
Native American/Alaska Native Languages
Other Languages (Please Specify)
Pacific Island Languages (Chuukese)
Pacific Island Languages (Hawaiian)
Pacific Island Languages (Kosraean)
Pacific Island Languages (Marshallese)
Pacific Island Languages (Pohnpeian)
Pacific Island Languages (Samoan)
Pacific Island Languages (Tongan)
Spanish
Spanish (Mexican, Central American, etc)
Other Language Proficiency
Little
Moderate
None
Proficient
Primary Health Coverage (Required)
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Other Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Doctor/Medical Home
AUDIOLOGIST-Kaiser
AUDIOLOGIST-MMG
AUDIOLOGY-MIKO
C.H.A.M.P.S. Pediatrics LLC
Dr. Frank Baum, MD
Dr. Gabrielle Galler-Rimm, MD
Dr. Joel Friedman MD
Dr. Steve Clark, MD
Hale Pawa'a-Kapiolani Specialist
Hana Health Center
Healthy Mother's Healthy Babies
HI Dermatology & Plastic Surgery
Hui No Ke Ola Pono
Imua Family Services
Jeffrey K Okamoto, MD
Kaiser
Kaiser OB Dept
Kapiolani Medical Center
Kihei-Wailea Medical Center
Lice Clinics of America-Maui
Malama I Ke Ola
Malama Pregnancy Center
Mango Medical/Pueo
Maui Center for Child Developmen
Maui Chatterbox
Maui Diagnostic Imaging
Maui Lani Physicians and Surgeon
Maui Medical Group
Maui Memorial Medical Center
Maui Skin Clinic
MEDQUEST
MEDQUEST Molokai
Molokai Community Health Center
Molokai General Hospital
Newborn Hearing Screening Progra
Nutritionist
Paniolo Pediatrics & Family Med
Pediatric Therapies of Hawai'i
Public Health Nurse
Shriners Hospital
Sky Connelly, CPM
Wailuku Health Center
Whole Body Wellness
Dental Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Dentist/Dental Home
Children's Dentistry of Maui
Dr. Brady Shirota, DDS
Dr. Byron Tsukano, DDS
Dr. Cally Adams, DDS
Dr. Emilie Sumida, DDS
Dr. Guy Horie, DDS
Dr. Jonathan Thomas, DDS
Dr. Lloyd Sahara, DDS
Dr. Neil Nunokawa, DDS
Dr. Ralph Kato, DDS
Dr. Shaun Wright, DDS
Dr. Shauna Pier, DDS
Hana Health Center
Hawaii Dental Clinic
Hawaii Smiles
HI Family Dental
Hui No Ke Ola Pono
Island Dental Maui
Just Keiki PED Dentistry
Kahului Dental
Kai Dental & Just Keiki Dental
Kanamori Dental
Malama I Ke Ola
Maui Dental Group
Maui Endodontics INC
Maui Family Dental
Maui Memorial Medical Center
Maui Pediatric Dentistry
Miyamoto Dental Design Suite
Molokai Community Health Center
Molokai General Hospital
Pedodontics Associates Inc. Maui
UH Maui College Campus
Valley Isle Dental
Virtual Dentistry Home
Wailuku Dental Group
Does your child have a disability or do you have any concerns about your child's development?
Yes
No
Is there anything else you want to tell us about your child?
Location Preferences
Which program are you applying for? (Required)
EHS 2024-2025
prenatal to age 3
Location Preference
<p></p>
1st Location Preference
<p></p>
2nd Location Preference
<p></p>
3rd Location Preference
<p></p>
- Your Address
- Available Locations
Click a location on the map to see more info
Click here
to find a provider in your area.
Additional Applicant
Do you want to apply now for another child in your family?
Add Another Applicant
Siblings
Are there other children in the family?
Add a Sibling
Please click submit to finalize your application. A staff member will call you to follow up on your application.
Required information is missing, see above.