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Head Start/Early Head Start Application
Justin Girard
2021-06-11T10:22:02-04:00
Head Start/Early Head Start Application
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?
Select a choice
EHS Home-Based
EHS Center-Based at 1198 Southard Street, Trenton
EHS Center-Based at Trenton Central High School (for infants/toddlers of TCHS students only)
EHS Center-Based at 1435 Liberty Street, Trenton (opening in 2021-2022)
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
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.
Input your primary language here.
How did you hear about us?
Select a Choice
Online Ad
Facebook
Instagram
Newspaper Ad
Direct Mail
Community Partner Referral
Participant Referral
Word of Mouth/Signage
Radio
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
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