Birth to 5 School Readiness Application

Birth to 5 School Readiness Program Application

Back to Birth to 5 School Readiness Program Page

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