Received ___/ ___/ ___ By ___________

Bank Street Head Start

535 E. 5th St., NY, NY 10009 (212) 353-2532 x236

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 federa , 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 Nombre

____/____/____ DOB Fecha de Nacimiento

___________________ Relationship to Child Relación con el niño/a

Phone Number __________________________________ (primary) or ___________________________________ Teléfono

(Primario)

Email Address ___________________________________ (primary) or ____________________________________ Correo Electrónico

(Primario)

Street Address________________________________________________________________________________________ Direccion

th

City, State/ Cuidad/ Estado

Zip Code/ Zona Postal

***Please note that you must live between 34 St. and Canal St. from east to west to be eligible for services at our site. ***Por favor tome nota, para ser elegible debe de vivir entre las calles 34 y Canal desde este o oeste.

Is this child a foster child? ________

If yes, name of agency ___________________________________________

Es su niño Foster?

Si, nombre de la agencia

Foster care worker _____________________________________________

Phone # ________________________

Nombre de trabajador del programa de Foster

Teléfono

Please list family members who live with the child Por favor de escribir todos los miembros de la familia quien viva con el niño/a. Check here if this member dependent Name DOB Relationship to on the parent/guardian’s income Nombre Fecha de Child Nacimiento

Revised 3/2016

Relación con el niño/a

Apunte si este miembro depende del ingreso del padre o guardián.

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? ______

Is English your child’s first language? ______

Es ingles su primer idioma?

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

_____________________________________________________________________________________________ Address / Direccion

City, State/ Cuidad/ Estado

Zip Code/ Zona Postal

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? Please check one Piense en su desarrollo de su niño/a , que repuesta mejor describe su niño/a? escoja una

___ I have no concerns.

____ I have some questions.

No tengo preocupaciones.

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 :

OT

PT

instrucciones especial

SEIT

Consejería

Speech

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 3/2016

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. Documents to bring with you when you submit your application (we will be happy to make copies): For your child:   

Birth Certificate Immunization Card Medicaid or Insurance Card

Your own: 

Proof of Address (TWO of the following): o Utility bill (gas or electric , i.e. Con Edison); must be dated within the past 60 days [we cannot accept telephone bills]. We cannot accept telephone and internet bills. o Mail from a Federal, State or local NY Agency (IRS, HRA, Medicaid, Social Security Letter, City Housing Authority, the Administration for Children’s Services (ACS)); must be dated within the past 60 days o Original lease agreement, deed, or mortgage statement for the residence; Official Rent receipt. o Current property tax bill for the residence o Notarized Department of Education Parent Affidavit of Residency form stating that you live at the address provided on the application o Official payroll document from an employer (example: payroll receipt); must be dated within the past 60 days



Proof of Income (ONE of the following for parent/s with whom the child resides): o Income Tax Return from the previous year (for applications submitted between January and June) o Three recent pay stubs o Recent public assistance voucher/Food Stamps/WIC letter o Unemployment or SSI letter o Notarized letter of financial support o Court documentation of the child support award from the non-custodial parent

Documents we will need if your child is enrolled: 

Revised 3/2016

Current physical on Bank Street Head Start form. We will need this form before the first day of school. Please plan to have it ready before the first day of school. Your child cannot begin without it!

Enrollment of Children with Special Needs 

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



Head Start is need based, and our goal is to serve families who have the most need. However, we must balance the needs of families with the needs of the classroom overall, keeping in mind that having many children with special needs or several children with extraordinary needs in a class requires a great deal of teacher attention, which can negatively impact the rest of the children.



Please be honest with us upfront. We are better able to make decisions regarding classroom placement and enrollment when we have all of the information about each child’s developmental needs.



Sometimes parents will attempt to hide any previous diagnosis or concerns about their child from the staff in the hope that this will increase the chances for acceptance. This is not the case. All children are required to attend a socialization group prior to enrollment decisions. Although this is just a brief look at the children, our highly experienced staff is quite skilled in quickly identifying concerns about deviation from what is typical for three and four year olds.



If it is discovered that a child has an IEP or IFSP that has not been revealed to Bank Street Head Start, the child’s continued enrollment will be reconsidered.



Any child who has an IEP or IFSP that recommends a center based program (that is, a higher child to teacher ratio than what we are able to provide) will not be enrolled at Bank Street Head Start.



Just as any parent who applies for the program may be informed that we cannot serve their child; the parent of a child with special needs may also receive the same response. All applications will be given full consideration but in the end there will be many aspects of each application that result in enrollment or disappointment. Our staff is available to assist parents in identifying and referring parents to other appropriate programs.

Revised 3/2016