HS/EHS Program Interest Form

Applicant Information

For Mercer County, NJ Residents Only

Please indicate if applicant is:*

Child
Pregnant/Mother

Number of Members in the Household

Has your child ever been enrolled in a Head Start program

Yes
No
N/A; I am applying as a Pregnant Mother

If yes, what is the name of the program?

Does your child have a sibling currently enrolled in our Head Start or Early Head Start program?

Yes
No
N/A; I am applying as a Pregnant Mother

Do you have a preferred site location?

Applicant Name*

Parent/Guardian’s Name (if applicable)

Expected Due Date (if applicable)

Month

Day

Year

Parent/Guardian’s Name (if applicable)

Applicant Birth Date*

Month

Day

Year

Address*

City*

ZIP*

Primary Phone*

Secondary Phone

Email

Enter Email Confirm Email

Primary Language

English
Spanish
Other

Input your primary language here.

How did you hear about us?

Name of Person/Organization That Referred You

Uploading Important Documents

Please select Child or Pregnant Mother applicant below to begin uploading your required application documents. All documents uploaded to our secure system will be maintained confidentially.

Please indicate if applicant is:*

Child
Pregnant Mother

Child's Birth Certificate

Max. file size: 8 MB.

Proof of address

Max. file size: 8 MB.

(choose one: current household utility bill; original deed/contract of sale; current lease; current mortgage statement; current property tax bill)

Proof of Income

Max. file size: 8 MB.

(all that apply: income tax form 1040; W2; current pay stubs; TANF documentation; SSI documentation; unemployment documentation; foster care reimbursement; verification letter from employer; if homeless- letter from shelter or other agency)

Child’s Universal Health Record / Physical Exam

Max. file size: 8 MB.

Child's Health Insurance Card

Max. file size: 8 MB.

Child’s immunization records

Max. file size: 8 MB.

Documentation of any Medical Conditions / Food Restrictions

Max. file size: 8 MB.

IEP or IFSP (if applicable)

Max. file size: 8 MB.

Proof of Pregnancy

Max. file size: 8 MB.

Proof of Address

Max. file size: 8 MB.

(choose one: current household utility bill; original deed/contract of sale; current lease; current mortgage statement; current property tax bill)

Second Proof of Address

Max. file size: 8 MB.

(choose one: current household utility bill different from 1st Proof of Address; current paystub AND telephone, cable, or internet bill; monthly benefits/bank statement; monthly insurance documents; document mailed from State or Federal agency

Proof of Income

Max. file size: 8 MB.

(all that apply: income tax form 1040; W2; current pay stubs; TANF documentation; SSI documentation; unemployment documentation; foster care reimbursement; verification letter from employer; if homeless- letter from shelter or other agency)

Health Insurance Card

Max. file size: 8 MB.

Photo ID

Max. file size: 8 MB.

Documentation of any Medical Conditions / Food Restrictions

Max. file size: 8 MB.

IEP (if applicable, for teen pregnant women attending high school or alternative school)

Max. file size: 8 MB.

Form Submission*

I/we will provide a physical copy of forms that were not electronically submitted

HS/EHS Program Interest Form

Applicant Information

*For Mercer County, NJ Residents Only*

Uploading Important Documents

Please select Child or Pregnant Mother applicant below to begin uploading your required application documents. All documents uploaded to our secure system will be maintained confidentially.

For Mercer County, NJ Residents Only