Parent/Guardian
First Name (Required)
Middle Name
Last Name (Required)
Birthday (Required)
Gender
Female
Male
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
Opt In for Text Messages
Yes
No
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
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Hispanic
Yes
No
English Proficiency
Little
Moderate
None
Proficient
Other Language
American Sign Language
English
French/Creole
Other
Spanish
Highest Grade Completed
Associate's Degree
Bachelor's Degree
College Degree/Training Cert.
College or Advance Training
General Education Diploma
Grade 10
Grade 11
Grade 12
Grade 9 or less
High School Graduate
Master's Degree
Employment Status
Full-time & Training
Full-time (35 hours/week or more)
Part-time & Training
Part-time (Under 35 hours/week)
Retired or Disabled
Seasonally Employed
Training or School
Unemployed
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Lives with Family
Yes
No
Provides Financial Support
Yes
No
Teen Parent
Yes
No
If Teen Parent, Subsidized?
Yes
No
Address
Is your family experiencing homelessness?
Yes
No
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
Address Line 2
City
State
ZIP
Additional Parent/Guardian
Is there another parent/guardian in the family?
Yes
No
First Name (Required)
Middle Name
Last Name (Required)
Birthday (Required)
Gender
Female
Male
Mobile Phone
Opt In for Text Messages
Yes
No
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.
Family Information
Number of Parents/Guardians
One Parent Family
Two Parent Family
Relationship to Participant(s)
Foster parent(s) not including relatives
Grandparent(s)
Other
Parent(s) (e.g. biological, adoptive, stepparents)
Relative(s) other than grandparents
Primary Language at Home
American Sign Language
English
French/Creole
Other
Spanish
Number in Family
Gross Annual Income
Is your family receiving cash benefits or other services under the Temporary Assistance for Needy Families (TANF) program?
Yes
No
Is your family receiving Supplemental Security Income (SSI)?
Yes
No
Is your family receiving services from WIC?
Yes
No
Is your family receiving services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps?
Yes
No
Is at least one parent/guardian an active duty member of the United States military?
Yes
No
Is at least one parent/guardian a veteran of the United States military?
Yes
No
Emergency Contacts
Add Emergency Contact
Child (Applicant)
First Name (Required)
Middle Name
Last Name (Required)
Suffix
Nickname
Birthday (Required)
Gender
Female
Male
Race
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Hispanic
Yes
No
English Proficiency
Little
Moderate
None
Proficient
Other Language
American Sign Language
English
French/Creole
Other
Spanish
Other Language Proficiency
Little
Moderate
None
Proficient
Primary Health Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Other Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Insurance Number
Doctor/Medical Home
A.M. Ricciardi
Advocare Kintir0glou Pediatrics
Advocare Summit Pediatrics
AFC Urgent Care
Agape Pediatric Center
Alba N. Mendez Morales, MD
Alexa Kemeny
All 4 Kidz Pediatrics
All Care Pediatrics
All Star Pediatrics & Sports Med
Alliance Community Healthcare
Allison Sopko
AMG Primary Care at Westfield
AMG-Pediatric Orthopedics
Andrea Alexander
Anjali Viswaratan
Ann M. Comandatore, MD
Anna Chan
Anthony Albanese
Antonio Thomas
Associates in ENT & Allergy
Atlantic Health Center
Atlantic Medical Group
Barbara LaBoard
Bayonne Medical Care
Bellevue Peadiatric
Benjamin Aubey, MD
Bloomridge Pediatrics
Bonnie Cai-Lou MD
Brian Lurie
Broadway Pediatrics
Brooklyn Plaza Medical Center
Central Jersey Medical Center
Chidi Achede
Children's Specialized Hospital
Childrens Hosp. Newark Beth Is
Chira Reddy
Chiu-Man Poon
Chukwemeka Ibeku
City MD Urgent Care
CityLife Neighborhood Clinics
Clara Mass Medical Cnter
Clifton Pediatrics
Constatinos Kintiroglou
Cotler
Curtis A. Johnson Jr, MD
Dahlia Hall
Dalia Pando
Daniele Kimble
Danilom Guito
David Levine, MD
Department of Pediatrics Doctors
Donna Lupski, MD
Dorothy Bisberg
Dr Coy
Dr Guy Delisfort
Dr Lander
Dr Reddy
Dr. Aluya
Dr. Amita Singh
Dr. Antonio Thomas
Dr. Doris A Huang
Dr. Guy Delifors
Dr. Kathyann Duncan
Dr. Kathyann Duncan
Dr. Lakshmi Gururajarao, MD
Dr. Lancaster
Dr. Maryan Phillips
Dr. Mathews
Dr. Mercedes EHS Health consulta
Dr. Mercedes Guiterriez
Dr. Myles
Dr. Myriam Spears
Dr. S. Periasamy
Dr. Satwari
Dr. Susan Yoo
Dr. Tokunbo Dada
Dr. Uma Kanikicharla
Dr.Gajarowala
Dresner, MD
East Orange Primary Care Center
Edgardo L. Tan, MD
Edgardo L. Tan, MD
Edith A. MCcarthy
Edwina Vener, MD
Emanuel Corbo, MD, FAAP
Emelle Emmanuel
Essex Pediatrics
Essex-Morris Pediatrics
Evergreen Medical Clinic P.C.
Family Care of NJ
Family Pediatrics
Fatema Jaffery
Fatema Jaffery
Faten Morkos
Fouad Rasheed
Foundation Pediatrics
Fragoso Pediatrics
Freidman Inga
Gloria N. Okoh, MD
Gloria N. Okoh, MD
Good Shepaherd Pediatric
Good Shepard Pediatrics
Grzybowski pediatrics
Guo-Pao Cheng, MD
Guy Francis
Hackensack Meridian Health
Harlem Hospital Center
Harrison Medical Group
Healthy Child Pediatrics
Honeygo Pediatrics
Howard Rosenblum
I. Obilo
Indu Madhok
Ingrid C. Brown, MD, FAAP
Integral Care Pediatrics
Ironbound Community Organization
Irvington Community Health Cente
Jacek Grzybowski
James Oleske
Jay Lovenheim
Jennifer L. May-Ortiz
Jesus Ortega
Jewish Rennaissance Medical Cent
JFK Family Medicine Center
Joanne Davine-Reicher, MD
Jose' Bustillo
Joseph L. Fernandez-Moure
Judith Hugh-Coffe, MD
Justina Anyanwu
K. Ayyanathan
Karen Lin, MD
Kate Speilholz MD
Kerri Powell, MD
Keyana Ruth
Kia C. Grundy
Kids Care Pediatrics
Kids Docs
Kinder Pediatiric
Kinder Pediatric Urgent Care
Krissantonia Kerr UC Health Dept
Kristina Shenk
Larry Gruenwald
Lezli L. Harvell, DMD
lincoln medical& Mental
Livingston Surgery Center
Lozano Rolando
Luis Garay, MD
M. Asfour
M. Calhoun Thomas, MD
M. Cora Cerdena
Madhavi Maniar
Madhavi Wijayaratne
Madhok, MD
Madolene Aliparo
Mahi Pediatrics
Malcolm X Shabazz High School
Marc Roberts
Marc Roberts, M.D.
Maria Boyle
Maria Toft
Maria Yeroui
Mark Camiolo, MD
Mark M. Benkel M.D.
Mary Daisy Cantey, MD
Mary Eliza Mahoney Health Center
MD Care Urgent Care
Mediterranean Pediatrics
Meggan Horowitz
Mejia Pediatrics LLC
Michaella M. Prasad M.D.
Millburn Pediatrics
Mona Ayoub MD
Morristown Medical Center
Mountainside Family Practice
Muhamm Siddique
My Whole Child Pediatrics
N Milanes-R
Nagi Eltemsah, MD
Neelam Khadke, M.D.
Neighborhood Health Center
Nelson Aluya
Newark Beth Israel Medical Cente
Newark Community Health Center
Newark Dept of Child & Family We
Newark School Based Health Cente
Nicole Panza Dr.
Nilesh Jariwala, MD
NJ Early Intervention System
NJ Family Practice Center
North Jersey Dental Center
NuHeights Pediatrics
Optical Academy
Optum Urgent Care
Oscar Pediatrics
Overlook Family Practice
P. Sundaram, MD
PASE Healthcare
Pauline Walks, MD
Pediatric Ambulatory/ Bellevue
Pediatric Denistry of Union
Pediatric Health Center
Pediatric Health Center
Pediatric Health Center
Pediatrics Specialties of Queens
Pediatries/Newark Dpt of Health
Pedimedica, PA
Pierre R. Leger, FAAP
PM Pediatrics
Poliana DaSilva, MD
Ponciano Palmery Jr, MD
Positive Health Care
Primary Care Partners Affiliate
R. Esquerre
Rainbow Pediatrics
Raksha Gajarawala
Rhomur Medical Services
Richard Lon
Ridgewood Pediatrics
Riverside Pediatric Group
Robert Wood Johnson University
Robin Winter
Ronke Dosunmu
Rosa Miranda, MD
Rosanna Mirante Dr.
Roseland Pediatrics
Ruchi Mehta
Rutgers Child Health Unit
Ryan Womens and Childrens Center
Saint Barnabas Medical Center
Saint Peters Hospital
SanJuan
Sayed Aly
Sebira Basu
Severiano San Juan Jr
Smile Dental
Sonu Khatri, APN
springfield pediatrics
St Barnabus Aids Resource Center
State of New Jersey DCP&P
Step By Step Pediatrics
Stephen Shroyer
Summit Health Pediatrics
Summit Medical Group
Summit Springfield Family Practi
Sunnyside Pediatrics
Suresh Patel
Susan Korb
Suzanne Botrous, MD
Teresa Manocchio
The University Hospital
Thomas Francis
Tokunbo Dada
Total Support Medical Group
Trinity Pediatrics
Uma Kanikicharle, MD
Uma Viswanathan, MDPA
UmaKanikicharle,MD
Union County immunization Center
Union County Lead Exposure Prev.
Union County Pediatrics Group
Union Pediatric Medical Group
Universal Pediatrics
University Hospital
University Pediatrics
Urban Health Plan, Inc.
Urgent Care Wlk in Medical Suite
Valley Health Partners Childrens
VAMA Medical Health Center
Veena Dhar, MD
Vesta N. Nnaeto
Vijaya Nimma
Virginio Rodriguez III
Vito Petrozzino
Watchung Pediatrics - Millburn
West Orange Pediatrics
Westfield Health Department
Weston PEdiatric Assoc.
Y. Michele Valdivso
Dental Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Dental Coverage Number
Dentist/Dental Home
Abradental
Academy Dental
Advocare Kintir0glou Pediatrics
AFC Urgent Care
Alliance Community Healthcare
Amalgamated Dental
Atlantic Health Center
Atlantic Medical Group
Bayonne Medical Care
Bloomridge Pediatrics
Bonnie Cai-Lou MD
Brilliant Smiles
Brooklyn Medical Plaza
Center for Family Dentistry
Central High Health Center
Central Jersey Medical Center
Child
Child Smiles
Child Smiles
Child Smiles
Children's Dental Health
Chukwemeka Ibeku
CityLife Neighborhood Clinics
Davia Strachan
Dental Health Associates
Dental Kidz
dentistry of children
Department of Pediatrics Doctors
Dr. Dewilder
Dr. Kathyann Duncan
Dr. Lee Smullen
Dr. Maryan Phillips
Dr. Skolnick
Dr. Steele
Edgardo L. Tan, MD
Fariba Sharifah
Fatema Jaffery
Gloria N. Okoh, MD
Good Shepaherd Pediatric
Grzybowski pediatrics
Hackensack Meridian Health
Harlem Hospital Center
Healthy Child Pediatrics
Heather Sculthorpe
Herbert Sabin, DDS, PA
Hudson Kids Dental
Indu Madhok
Irvington Community Health Cente
ISmile Dental Care
Jacob Plawner
Jennifer L. May-Ortiz
Jesus Otega
Jewish Rennaissance Medical Cent
Joanne Davine-Reicher, MD
Kate Speilholz MD
Kids Care Pediatrics
Kidz Dental
KinderSmile
Laser Dental Group PC
Lezli L. Harvell, DMD
Little Smiles
Lucy A. Chan-Wong, DMD
Madhavi Wijayaratne
Malcom X Shabazz
Marc Roberts MD
Marigold Pediatric Dentistry
Mark M. Benkel M.D.
Mary Eliza Mahoney Health Center
MD Care Urgent Care
Morgan Dental
Mouli Surti
Mountainside Family Practice
Nanci Tofsky
Newark Beth Isreal Medical Cente
Newark Community Health Center
Newark Dept of Child & Family
NJ Early Intervention System
NJ Family Practice Center
NJ KIds Ped Group
Norman Schwartz, DMD, PA
North Jersey Dental Center
Optum Urgent Care
Orange Dental Group
Pearly Whites
Pediatric Ambulatory/ Bellevue
Pediatric Denistry of Union
Poliana DaSilva, MD
RJ Dental
Roseland Pediatrics
Rutger's School of Dental Medici
Ryan Womens and Childrens Center
Severiano San Juan Jr.
Shah Dr.
Smile Dental
Smile Studio
Somerset Pediatric Dentist
Sonu Khatri, APN
State of New Jersey DCP&P
Step By Step Pediatrics
Summit Health Pediatrics
Supreme Dental Associates
Suzanne Botrous, MD
Tender Smiles of Roselle
The Smile Express
UmaKanikicharle,MD
University Pediatrics
Urgent Care Wlk in Medical Suite
Does your child have a disability or do you have any concerns about your child's development?
Yes
No
Is there anything else you want to tell us about your child?
Location Preferences
Which program are you applying for? (Required)
Private/Preschool
Early Head Start
Location Preference
<p></p>
1st Location Preference
<p></p>
2nd Location Preference
<p></p>
3rd Location Preference
<p></p>
- Your Address
- Available Locations
Click a location on the map to see more info
Click here
to find a provider in your area.
Additional Applicant
Do you want to apply now for another child in your family?
Add Another Applicant
Siblings
Are there other children in the family?
Add a Sibling
Required information is missing, see above.