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HELP New Mexico, Inc.
ADVOCACY | EMPOWERMENT | ADVANCEMENT
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Find Child Care
Find Basic Support
Find Housing Assistance
Find Food Assistance
Find Employees
Locations
Short-Term Housing Stabilization Assistance
Menu
About
About Us
Events
Executive Management
Board of Directors
Leadership Council
Programs
Find Education
Find a Job
Find Child Care
Find Basic Support
Find Housing Assistance
Find Food Assistance
Find Employees
Locations
Short-Term Housing Stabilization Assistance
Child Application
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
Home Address
Home Address
Home Address
City
City
State/Province
New Mexico
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
Mailing Address if different from Home Address
Mailing Address if different from Home Address
Mailing Address if different from Home Address
Mailing Address if different from Home Address
City
City
State/Province
New Mexico
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
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
F
M
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
F
M
Total Number of Household Including Self
Please upload applicable documents here (immunizations, etc.)
Drop a file here or click to upload
Choose File
Maximum file 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
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30
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45
50
55
AM
PM
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