FSP Minor Application

THE MAUI FARM

FAMILY STRENGTHENING PROGRAM (FSP)

Please submit an application for each minor that will be residing with you at The Maui Farm. An FSP Adult Application should be completed prior to this application.

For any questions or concerns, contact us at (808) 579-8271

Date

Application Code

An application code is in the confirmation email sent by Smartsheet to the email you provided in your application. (ex. ADULT00001)

Parent/Legal Guardian Name

First and Last Name

Relationship to Minor

Parent/Legal Guardian Email

Parent/Legal Guardian Phone Number

Minor Name

First and Last Name

Minor Sex

Minor Date of Birth

mm/dd/yyyy

Minor Age

Minor Demographics

Victimization Type

Please select all that apply to the minor below

Minor's Father's Name

First and Last Name of minor's father

Where is minor from?

With Whom is This Minor Currently Residing?

Custody of Minor

Please select the custody you have of this minor

Minor Health Insurance

Health Information

Does this minor have any health conditions we should be aware of?

Ex. Bee allergy- requires EpiPen

Minor Disability

Does this minor have any disabilities that require reasonable accommodation? If so, what accommodations do they need?

Support Organizations

Is this minor receiving support from any other organizations? Please select all that apply.

Maui Wildfires

Has this minor been affected by the August 2024 Maui Wildfires?

(ex. other parent lost their home or job, loss of school or childcare)

Additional Information or Comments

Any additional information or comments you would like to share?

Send me a copy of my responses

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