Birth to 5 School Readiness Program Application

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Thank you for your interest in the Birth to 5 School Readiness program. The application lists the necessary materials for a completed application.  Applications will not be considered until all required documents are completed. 

 

 

Expectant Mother Application

Center-Based Program Application

Center-Based Application

Items Needed for Completion of Application: 

  • Completed Application

  • Proof of Current Address

  • Copy of Child’s Birth Certificate

  • Copy of Child’s Medical Insurance Card

  • Signed Pediatric Medical Release Form (Provided in the application)

  • Completed Medical Statement

    • (Please take this form to your child’s physician for completion)

  • Custody Papers (if Applicable)

  • Copy of families SSI eligibility(if Applicable)

  • Verification of Income:

    • Last year’s Tax Returns, W2’s or 12 months of Pay Stubs

    • See next page if you have questions

  • Most Recent Dental Record if available

 

You may Drop off, Mail or Fax your completed application to:

Enrollment Facilitator

650 Baldwin Street

Elmira, NY 14901

Fax: 607-733-0598

 

Please call with any questions:

Amy Willette, Manager ERSEA Services

(607) 734-6208, ext. 276

Home-Based Program Application

Home-Based Application

Items Needed for Completion of Application

  • Completed Application

  • Proof of Current Address

  • Copy of Child’s Birth Certificate

  • Copy of Child’s Medical Insurance Card

  • Signed Pediatric Medical Release Form Provided in the application

  • Completed Medical Statement 

    • (Please take this form to your child’s physician for completion)

  • Custody Papers (if Applicable)

  • Copy of Child’s SSI eligibility(if Applicable)

  • Verification of Income:

    • Last year’s Tax Returns, W2’s or 12 months of Pay Stubs

    • See next page if you have questions

  • Most Recent Dental Record if available

 

You may Drop off, Mail or Fax your completed application to:

Enrollment Facilitator

650 Baldwin Street

Elmira, NY 14901

Fax: 607-733-0598

 

Please call with any questions:

Amy Willette, Manager ERSEA Services

(607) 734-6208, ext. 276