APPLICATION Start Date -
COMMUNITY COLLEGE CHILDREN'S CENTERS Preferred Child Care
Days -
Child's Legal Name
Last Name First Name Middle Name
Date of Birth Gender: Boy Girl
Nickname Special Needs
Children's Center: HonCC-Keiki Hauoli Children's Center LeeCC Children's Center
KapCC-Alani Children's Center
Campus: Parent Status: #1 #2 Preferred Starting Semester: Preferred Child Care:
HonCC New Student Fall Full
KapCC Continuing Student Spring M/W/F
LeeCC Faculty T/Th
Other UH Lecturer Other
Staff Not Sure
Other UH
Non-UH/Community
Parent/Guardian (Primary contact):
Name UH ID (if applicable) Relationship to child
Address City Zipcode
Preferred contact phone number: Best time to contact:
Email: Marital Status: Married Single
Parent/Guardian (Secondary Contact if unable to reach Primary):
Name UH ID (if applicable) Relationship to child
Address City Zipcode
Preferred contact phone number: Best time to contact:
Email: Marital Status: Married Single
Signature of Parent/Guardian Date
Date Received by Children's Center
