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Head Start Application
Justin Girard
2021-03-10T12:28:22-05:00
Head Start Application
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?
Select a choice
Home-Based Head Start/Early Head-635 South Clinton Avenue Trenton, NJ 08611
Bellevue Head Start Center-715 Bellevue Avenue Trenton, NJ 08610
East State Street Head Start Center-794 East State Street Trenton, NJ 08608
Smith Santiago Head Start/Early Head Start Center-1198 Southard Street Trenton, NJ 08638
St. Bartholomew Head Start Center-1746 South Clinton Avenue Trenton, NJ 08610
Liberty Street coming soon (Spring, 2021)
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?
Select a Choice
Advertisement
Newspaper
Radio
Word of Mouth
Partner Referral
Facebook
Instagram
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
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
Child’s immunization records
Children with disabilities: Provide an IFSP or IEP
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
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