Child Application – HELP New Mexico Inc.

HELP New Mexico, Inc. Child Application

This application is used to determine eligibility for all HELPNM Office of Learning & Academic Opportunity. Please answer all the questions on the form, sign application and return for a certification interview. If you need assistance with this application, please contact center staff. Thank You.

Section 1: Parent/Legal Guardian (Primary Caregiver)

Full name: First Name, Middle Initial, Last Name

Date of Birth

Gender

Female

Male

Home Address

City

State/Province

Zip/Postal

Mailing Address if different from Home Address

City

State/Province

Zip/Postal

Home Telephone

Cell Telephone

Work Telephone

Relation to Applicant

Email Address

Family Type (check one)

One Parent Family

Two Parent Family

Section 2: Child(ren) Applying for Child Development Services

Complete the following for each child applying for Child Development Services:

First Name

Last Name

Middle Name

Birth Date

Age

Relation to You

Gender

Section 3: All Other Household Members

Complete the following information for all other people who live with you that are supported by your income and related
to you by blood, marriage, or adoption.
(Do not list the children already listed above.)

First/ Last Name

Birth Date

Age

Relation to Applicant

Gender

Total Number of Household Including Self

Please upload applicable documents here (immunizations, etc.)

Maximum upload size: 10.49MB

I understand that the information provided is correct to the best of my knowledge and this information will be kept in strict confidence. All information provided is used to determine eligibility and priority selection.

Parent/Guardian Signature

Date

FOR OFFICE USE ONLY

Date Application Received

Time Application Received

Received By

Comments

Section 1: Parent/Legal Guardian (Primary Caregiver)

Section 2: Child(ren) Applying for Child Development Services

Section 3: All Other Household Members

FOR OFFICE USE ONLY

How can we help you?