FSP Minor Application

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*

Select

Minor Date of Birth*

Minor Age*

Select

Childcare Provider*

Is the minor in childcare? Please share the name of the childcare provider below.

School Name*

Minor Demographics*

Select

Victimization Type*

Please select all that apply to the minor below

Select

Minor's Father's Name*

First and Last Name of minor's father

Where is minor from?*

Select

With Whom is This Minor Currently Residing?*

Select

Custody of Minor*

Please select the custody you have of this minor

Select

Custody or Coparenting Arrangement*

Custody schedule, who is sharing custody, is this a legal arrangement?

Minor Health Insurance*

Select

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.

Select

Other Support Organizations*

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)

Select

If Yes, Please Explain*

Please explain how this minor has been affected by the wildfires. Be specific.

Additional Information or Comments

Any additional information or comments you would like to share?

DOCUMENTS CHECKLIST*

Please upload the following documents for this minor:

Birth Certificate

Legal Guardianship or Adoption Paperwork

Custody Agreement

Drag and drop files here or

Send me a copy of my responses

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