Head Start/Early Head Start Interest Form *For Mercer County, NJ Residents Only*Date of Interest MM slash DD slash YYYY I am completing this form for multiple people* Yes No 1st Form – Please indicate if application is for:* Head Start Child (age 3-5) Early Head Start (age 0-3) EHS Pregnancy Services 2nd Form – 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 choiceHS Center Based 715 Bellevue AvenueHS Center Based 1198 Southard StreetHS Center Based 794 E. State StreetHS Center Based 1746 S. Clinton AvenueEHS Home-BasedEHS Center-Based at 1198 Southard Street, TrentonEHS 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 Services1st Applicant Name*2nd Applicant Name*Parent/Guardian’s Name (if applicable)1st Applicant Birth Date* Month Day Year 2nd 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.EnglishSpanishOther**If you selected "Other" under languages, please enter other language here.*Address*City*ZIP*Primary Phone*Secondary PhoneEmail Enter Email Confirm Email How did you hear about us?Select a ChoiceCommunity Partner Organization*Direct MailFacebookHS/EHS Participant Referral*HS/EHS Staff Outreach in Community*InstagramNewspaper AdOnline AdOpen HouseOther CHSofNJ Program/Staff*PRA-SPECTSite SignageWord of Mouth**Name of Person/Staff/Organization the Referred YouUploading 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 2nd applicant is:* Child Pregnant Mother Please indicate if 1st applicant is:* Child Pregnant Mother 1st Child's Birth CertificateMax. file size: 50 MB.2nd Child's Birth CertificateMax. file size: 50 MB.Proof of addressMax. file size: 50 MB.(choose one: current household utility bill; original deed/contract of sale; current lease; current mortgage statement; current property tax bill)Proof of IncomeMax. file size: 50 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)1st Child’s Universal Health Record / Physical ExamMax. file size: 50 MB.2nd Child’s Universal Health Record / Physical ExamMax. file size: 50 MB.1st Child's Health Insurance CardMax. file size: 50 MB.2nd Child's Health Insurance CardMax. file size: 50 MB.1st Child’s immunization recordsMax. file size: 50 MB.2nd Child’s immunization recordsMax. file size: 50 MB.1st Applicant Documentation of any Medical Conditions / Food RestrictionsMax. file size: 50 MB.2nd Applicant Documentation of any Medical Conditions / Food RestrictionsMax. file size: 50 MB.1st Child IEP or IFSP (if applicable)Max. file size: 50 MB.2nd Child IEP or IFSP (if applicable)Max. file size: 50 MB.Proof of PregnancyMax. file size: 50 MB.Proof of AddressMax. file size: 50 MB.(choose one: current household utility bill; original deed/contract of sale; current lease; current mortgage statement; current property tax bill)Second Proof of AddressMax. file size: 50 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 agencyProof of IncomeMax. file size: 50 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 CardMax. file size: 50 MB.Photo IDMax. file size: 50 MB.CAPTCHAForm Submission* I/we will provide a physical copy of forms that were not electronically submitted
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