Date: _____________ Initial:_____

535 E. 5th St., NY, NY 10009 Phone# (212) 875-4737 Fax# (212)995-1280

Application / Solicitud Head Start is a federally funded, free program for income eligible families. We keep the information you share with us strictly confidential. We use it to determine eligibility, but also to begin the process of getting to know you. Head Start es un programa federal , es gratis para familias acuerdo su ingreso. Mantenemos su información confidencial. Su información nos ayudara determinar su elegibilidad y comenzar su solicitud para conocerlo usted y su familia.

__________________________________________ Child’s Name

____/____/____ DOB

_______ Gender

________________ Child’s Nickname

Nombre del Nino

Fecha de Nacimiento

Sexo

Apodo

Parent/Guardian Information Información del Padre/ Guardian _____________________________________

____/____/____

Name Nombre

DOB Fecha de Nacimiento Relationship to Child Relación con el niño/a

_____________________________________

____/____/____

Name

DOB Fecha de Nacimiento

Nombre

Phone Number __________________________________ or Teléfono Email Address _____________________________________ or Correo Electrónico

___________________ ___________________ Relationship to Child Relación con el niño/a

_______________________________________ ______________________________________

______________________________________________________________________________________________ Address /Direccion

City, State/Cuidad/ Estado

Zip Code/Zona Postal

Is this child a foster child? ________

If yes, name of agency ___________________________________________

Es su niño Foster?

Si, nombre de la agencia

Foster care worker _____________________________________________ Nombre de trabajador del programa de Foster

Phone # ________________________ Teléfono

List family members who live with the child./ Escribir todos los miembros de la familia quien viva con el niño/a. Name DOB Relationship to Child Check here if this member dependent Nombre Fecha de Relación con el niño/a on the parent/guardian’s income Nacimiento Apunte si este miembro depende del ingreso del padre o guardián.

Revised Jan. 2019

Your answers to these next questions will help us get to know your child and your family. Please note that we serve children with special needs. Su contestación en las próximas preguntas nos ayudara conocer más a su niño o niña y su familia. Por favor tome nota que trabajamos con niños con necesidades especiales. Is English your first language? ______ Es ingles su primer idioma?

Is English your child’s first language? ______ Es inglés es primer idioma del Niño/a ?

Language/s spoken at home: ______________________________________________________________________ Que lenguas o idiomas se hablan en casa? Gross Annual Income $_________________________ (Please provide proof of income, see the attached page for details.) El ingreso anual antes de los impuestos (por favor de prueba de ingreso, vea la siguiente página para más detalles) Is the parent/Guardian currently employed or attending school? _________ Usted, el padre/ guardián está trabajando o asistiendo una escuela? If yes, Name of Employer/School : ________________________________________________________________ Si, Nombre de Empleo o Nombre de la Escuela Days/Hours of Employment/Classes Per Week: ________________________________________________________ Días/ Horas del empleo o clases durante la semana Does your child currently attend school or day care? ________ If yes, please describe: ______________________ Esta su niño asistiendo una escuela o day care reciente? Si, por favor de describe Is your child toilet trained? ____________ Su niño/a ha dejado el panel?

Does s/he take naps at home? __________ Toma su Niño/a siesta en casa?

Thinking about your child’s development, which sentence best describes your child? Piense en su desarrollo de su niño/a , que repuesta mejor describe su niño/a? ___ I have no concerns. No tengo preocupaciones.

____ I have some questions. Tengo algunas preocupaciones.

____I have some concerns. Tengo preocupaciones.

Is there something about your child that you are especially proud of? ______________________________________ Hay algo en su niño/a que usted está especialmente orgulloso del él? _______________________________________________________________________________________________ Is there anything that you are feeling worried about as a parent, or that’s hard for you? _______________________ Le preocupa algo come padre o algo que sienta dificultoso? _______________________________________________________________________________________________ Is your child receiving or has s/he received services through EI, CPSE or private insurance? _____________________ Su niños está recibiendo o ha recibido servicios de intervención temprana como EI, CPSE o atraves de su seguro privado ? If yes, circle the services: Speech OT PT Special Instruction SEIT Counseling Si, circular los servicios : Speech OT PT instrucciones especial SEIT Consejería Is there anything else that you would like to tell us about your child, yourself or your family? ___________________ Díganos algo más sobre su niño o niña, algo sobre usted o su familia? _______________________________________________________________________________________________ How did you hear about our program? Como supo del nuestro programa? _________________________________________ Revised Jan. 2019

Instructions Once you have filled out the application, please bring it in with the documents listed below so that we can begin to process your application. No application will be processed unless all documents have been submitted. We can make copies for you. Child’s: Birth Certificate (or passport or NYS identification card or record of baptism)  

Immunization Card Medical Insurance Card

Proof of Address: Two (2) of the following:     

      

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Current lease agreement, deed, property tax bill or mortgage statement for the residence; Rent receipt with address of residence dated within the past 60 days Residence utility bill (gas or electric) in the resident’s name issued and dated within the past 60 days A bill for cable television services provided to the residence; must include the name of the parent dated within the past 60 days Documentation or letter on letterhead from a federal, state, or local government agency (ex: IRS, NYCHA, the federal Office of Refugee Resettlement, Human Resources Administration, or the Administration for Children’s Services (ACS), ACS subcontractor, indicating the resident’s name and address, and dated within the past 60 days A water bill for the residence; must be dated within the past 90 days; Current state, city, or other government issued identification with address of residence (NYS driver’s license or learner’s permit, NYS non-driver identification card, or IDNYC card, Income tax form or W-2 with for the last calendar year with address of residence Current official payroll documentation from an employer with your address (pay stub, or tax withholding form) issued within the past 60 days Voter registration documents, which include the name of the parent and the address of residence; Current membership documents based upon residency (e.g., neighborhood residents’ association), which include the name of the parent and the address of residence Evidence of custody of the child, including but not limited to judicial custody orders or guardianship papers; documents must have been issued within the past 60 days and include name of student and address of residence. Letter from shelter/temporary housing program on letterhead verifying child’s/family’s residence

Proof of Income: One (1) of the following for the parent(s)/guardian(s) with whom the child resides) o o o o

Revised Jan. 2019

Income Tax Return or W-2 from the previous year Three recent pay stubs Current TANF (public assistance), SNAP (food stamps), WIC, Unemployment Benefits, SSI or SSD documentation Court documentation of the child support award from the non-custodial parent

Enrollment of Children with Special Needs 

Bank Street Head Start is an inclusive setting. Typically 15-40% of our children have special needs.

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Head Start is needs based, our goal being to serve families with the most needs. However, children with special needs require a great deal of teacher assistance and support. Classes must be balanced in order for teachers to give all students the attention that they need, allowing for the smooth functioning of the class and positive experience for the students.

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At times, parents may not share that their child has a current or previous diagnosis or that they have concerns about their child’s development for fear that he/she may not be accepted to our program or will be “labeled” as a special needs child in the future. This is not the case. Please share as much information as possible about your child to insure appropriate school placement as we may or may not be able to serve his/her needs.

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In addition, all children applying to our program are required to attend a socialization/play group prior to enrollment decisions. Although this is just a brief interaction with the child, our highly experienced early childhood staff is quite skilled in quickly identifying concerns about deviation from typical childhood development.

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We are better able to make decisions regarding enrollment and classroom placement when we have all of the information about each child’s developmental needs. If we learn at a later date that a child has and IEP or IFSP that has not been shared with Bank Street Head Start, the child’s continued enrollment will be reconsidered.

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Any child who has an IEP or IFSP that recommends a center based program (has a higher child to teacher ratio) or other supportive services that we are not able to provide according to our abilities and mandates the child will not be enrolled at Bank Street Head Start.

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All Bank Street Head Start applicants have the same application process. Children may or may not be accepted, or may be waitlisted for various reasons. Our staff is available to assist parents in identifying and referring parents to other programs if needed.

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Please remember that providing accurate information upon applying is key to insuring that your child attends a school where all of his/her needs are met in a timely manner in order for him/her to have a positive school experience and to make progress.

Revised Jan. 2019