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Head Start/Early Head Start Application
Emily
2021-06-11T10:22:02-04:00
Head Start/Early Head Start Application
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?
Select a choice
HS Center Based 715 Bellevue Avenue
HS Center Based 1198 Southard Street
HS Center Based 794 E. State Street
HS Center Based 1746 S. Clinton Avenue
EHS Home-Based
EHS Center-Based at 1198 Southard Street, Trenton
EHS Center-Based at 1435 Liberty Street, Trenton (opening in 2021-2022)
EHS Center-Based at Trenton Central High School (for infants/toddlers of TCHS students only)
EHS Pregnancy Services
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.
English
Spanish
Other*
*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?
Select a Choice
Community Partner Organization*
Direct Mail
Facebook
HS/EHS Participant Referral*
HS/EHS Staff Outreach in Community*
Instagram
Newspaper Ad
Online Ad
Open House
Other CHSofNJ Program/Staff*
PRA-SPECT
Site Signage
Word of Mouth*
*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
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