Birth to 5 School Readiness Program Application
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.
Items Needed for Completion of Application
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Completed Application
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Proof of Current Address
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Copy of Child’s Birth Certificate
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Copy of Child’s Medical Insurance Card
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Signed Pediatric Medical Release Form Provided in the application
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Completed Medical Statement
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(Please take this form to your child’s physician for completion)
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Custody Papers (if Applicable)
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Copy of Child’s SSI eligibility(if Applicable)
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Verification of Income:
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Last year’s Tax Returns, W2’s or 12 months of Pay Stubs
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See next page if you have questions
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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
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
Center-Based Program Application
