HS/EHS Program Interest Form

Complete this brief form to let us know you’d like to enroll in our Head Start or Early Head Start program! We’ll be in touch very soon (typically within 48 hours) to learn more about you and your child, and to help complete your application to enroll.

If you have trouble completing this form, call (609) 695-6274 Ext. 213 for assistance.

The Children’s Home Society of New Jersey (CHSofNJ) Head Start/Early Head Start (HS/EHS) program provides high quality early childhood education and comprehensive services for children ages birth through 5 in Trenton, New Jersey. Our EHS program also provides education and support services for pregnant women. All services are provided at no cost to families. For detailed descriptions of our Center-Based HS/EHS program serving infants, toddlers, and preschool aged children, click here. To learn more about our Home-Based EHS program serving infants, toddlers, and pregnant women, click here. To learn about our services to pregnant women, click here.

Services are in-person for fall 2021, in accordance with local, State, and Federal COVID-19 safety guidance.

Applicant Information
*For Mercer County, NJ Residents Only*
Date of Interest
MM slash DD slash YYYY
Please indicate if application is for:*
- Head Start Child (age 3-5)
- Early Head Start (age 0-3)
- EHS Pregnancy Services
Do you have a preferred site location?
Applicant Name*
Parent/Guardian’s Name (if applicable)
Applicant Birth Date*
Month
Day
Year
Expected Due Date (if applying for EHS Pregnancy Services)
Month
Day
Year
Languages Spoken (This will help us connect you with staff best able to communicate with you clearly and effectively). Please select all that apply.
*If you selected "Other" under languages, please enter other language here.*
Address*
City*
ZIP*
Primary Phone*
Secondary Phone
Email
Enter Email Confirm Email
How did you hear about us?
*Name of Person/Staff/Organization the 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: 4 MB.
Proof of address
Max. file size: 4 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: 4 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: 4 MB.
Child's Health Insurance Card
Max. file size: 4 MB.
Child’s immunization records
Max. file size: 4 MB.
Documentation of any Medical Conditions / Food Restrictions
Max. file size: 4 MB.
IEP or IFSP (if applicable)
Max. file size: 4 MB.
Proof of Pregnancy
Max. file size: 4 MB.
Proof of Address
Max. file size: 4 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: 4 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: 4 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: 4 MB.
Photo ID
Max. file size: 4 MB.
Documentation of any Medical Conditions / Food Restrictions
Max. file size: 4 MB.
IEP (if applicable, for teen pregnant women attending high school or alternative school)
Max. file size: 4 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