Head Start Application - CHSofNJ New site 2020

Applicant Information

For more information please contact us at 609-695-6274 x213

***This Application is for Mercer County, New Jersey Residents Only

Please indicate if applicant is:*

Child
Pregnant/Mother

Number of Members in the Household

Is your child currently enrolled in a Pre-K program

Yes
No

Has your child ever been enrolled in a Head Start program

Yes
No

If yes, what is the name of the program?

Do you have a preferred site location?

Applicant Name*

Parent's Name (if applicant is a minor)*

Expected Delivery Date

Applicant Birth Date*

MM

DD

YYYY

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

ALL FORMS REQUIRED**

Please attach the following documents for Head Start and Abbott • Rent Lease Agreement • 2 Utility bills • A Letter from the Department of Social Services • Income for both parents • Child’s birth certificate • Immunization records • Physicals

First Select Age:

Head Start (3-5)
Early Head Start (1-2)
Pregnant Women

Proof of address

(Choose one: current household water, electricity, or gas bill, original deed / contract of sale, current lease, current mortgage statement, or current property tax bill)

Proof of address

(Choose one: current household water, electricity, or gas bill, original deed / contract of sale, current lease, current mortgage statement, or current property tax bill)

Proof of address

(Choose one: current household water, electricity, or gas bill, original deed / contract of sale, current lease, current mortgage statement, or current property tax bill)

Proof of Address 2

(Choose one: current household utility bill different from #1, 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

(All that apply: Income tax form 1040, W2, current pay stubs, TANF documentation, SSI documentation, unemployment, foster care reimbursement, written letter of verification from employer)

Proof of Income

(All that apply: Income tax form 1040, W2, current pay stubs, TANF documentation, SSI documentation, unemployment, foster care reimbursement, written letter of verification from employer)

Proof of Income

(All that apply: Income tax form 1040, W2, current pay stubs, TANF documentation, SSI documentation, unemployment, foster care reimbursement, written letter of verification from employer)

Health Insurance Card

Child's Health Insurance Card

Proof of Pregnancy

Photo ID

Child's Birth Certificate

Proof of any food restrictions or medical conditions

Food restrictions or medical conditions

(not applicable)

Child’s immunization records

Children with disabilities: Provide an IFSP or IEP

(not applicable)

Child's Birth Certificate

Proof of any food restrictions or medical conditions

Food restrictions or medical conditions

(not applicable)

Child’s Universal Health Record / Physical Exam

Children with disabilities: Provide an IFSP or IEP

(not applicable)

Form Submission*

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