Apply Online

If you've already submitted an application for our program, have a child or children enrolled, or have received services for yourself, we kindly ask that you don't fill out a new application. Instead, please feel free to reach out to our ERSEA Manager, Marlena Rivera, at 856-300-2625, and she will be happy to assist you!

First Name (Required)

Middle Name

Last Name (Required)

Birthday (Required)

Gender

Email Address (Required)

Confirm Email Address

It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.

Mobile Phone (Required)

Home Phone (Required)

Work Phone (Required)

Ext.

It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.

Race and/or Ethnicity - To specify multiracial and/or multiethnic please check all races and/or ethnicities that apply (Required)

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White

Prefer not to answer

Employment Status

Child's Relationship (Required)

Is your family experiencing homelessness?

Living Address (Required)

Address Line 2

City (Required)

State (Required)

ZIP (Required)

Click here to find a provider in your area.

Mailing Address same as Living Address

Mailing Address (Required)

Address Line 2

City (Required)

State (Required)

ZIP (Required)

Is there another parent/guardian in the family?

First Name (Required)

Middle Name

Last Name (Required)

Birthday (Required)

Gender

Email Address

Confirm Email Address

It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.

Mobile Phone

Home Phone

Work Phone

Ext.

It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.

Race and/or Ethnicity - To specify multiracial and/or multiethnic please check all races and/or ethnicities that apply (Required)

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White

Prefer not to answer

Employment Status (Required)

Child's Relationship (Required)

Number of Parents/Guardians

Relationship to Participant(s)

Primary Language at Home

Is another language being acquired or learned at home?

Number in Family

Gross Annual Income

If you need to apply for multiple siblings, please add the siblings to the existing application. There is no need to submit separate applications. For expectant mothers completing an application for themselves, where it reads "Child (applicant)," please enter "Baby" as the first name and your last name. Your due date will be the date of birth.

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Birthday (Required)

Gender

Race and/or Ethnicity - To specify multiracial and/or multiethnic please check all races and/or ethnicities that apply (Required)

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White

Prefer not to answer

Lives with Family (Required)

English Proficiency

Other Language

Other Language Proficiency

Is there anything else you want to tell us about your child?

Does child have IEP/IFSP

Receiving Gateway Servic

Which program are you applying for? (Required)

Location Preference

1st Location Preference

2nd Location Preference

3rd Location Preference

- Your Address - Available Locations

Click a location on the map to see more info

Click here to find a provider in your area.

Do you want to apply now for another child in your family?

Add Another Applicant

Are there other children in the family?

Add a Sibling

Thank you for completing the pre-application process. The assigned ERSEA Associate will contact you within 24-48 hours to schedule an intake appointment. For the intake appointment 1. Proof of Child’s Age A. Birth Certificate B. Parents’/ Guardians' Legal Identification Card (ID, Passport) 2. Proof of Income A. Recent and consecutive pay stubs; 2 recent biweekly or 4 recent weekly, W-2, or 1040. B. Recent award letter from the Board of Social Services for TANF or SNAP. • Award letter for SSI (Supplemental Security Income). • Award letter for Social Security benefits, disability, retirement, or survivor benefits. C. Unemployment benefits notice of determination letter. D. Any other income that the family receives. 3. Health Insurance information for the enrolling child or children 1. Proof of vaccinations/immunizations

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Family Information

Child (Applicant)

Location Preferences

Additional Applicant

Siblings