About Us
Programs & Applications
Support Our Work
Community Meetings
Partners & Advocates
Enrolled Families
The Programs
The Benefits
The Requirements
The Application
The Forms & Worksheets
Self-Employed Information
Frequently Asked Questions

Return to Home

Application Request

Do Not use this form for your annual review.  Please click here to select the renewal form.

Please complete this form and click the Submit button when you have finished.  After you submit your information you can download and print an application. Fill out the application and mail it to NH Healthy Kids 1 Pillsbury Street Suite 300, Concord, NH 03301

You can also request that an application be sent to you by clicking on the box below.

First Name    
Last Name  
Address:  
Apt. #:  
Town:  
State:  
Zip:     Use 5 digits only
County:  
Phone:     Do not use dashes
Where did you hear about NH Healthy Kids?

Have you applied to Healthy Kids before?
Yes       No 

Please send me an application.
I would like to download a printable application.

NOTE:  Clicking "Submit" above will take you to the form verification page and open up the NH Healthy Kids Application in a new Window in your browser.  Javascript is used to perform this task.  Some old browsers do not support Javascript, in addition some people choose to disable Javascript within their browsers.  In these cases the form may not load correctly.  If you have any trouble you can click here to download the application ().  

 
  Items marked with this symbol require the Adobe Acrobat Reader for viewing. Click the link below to be taken to the Adobe website to download the (free) Reader
 

©2006 New Hampshire Healthy Kids. Designed by Millennium Advertising