Application # __________ Assurance of Confidentiality: All information shared will be held in strict confidence. The Children’s Aid Society Early Childhood Programs Application 2016-2017 PS5 PS8 PS50 PS152 CS211 CS61 E. Harlem F. Douglass BECC D.Hamilton Richmond Taft SIFSC Milbank *Site Contact Info Attached FAMILY CHILD’S NAME_____________________________________________________________________________________________________ (Last) (First) (Middle) BIRTHDATE:_______________________________ GENDER: (Please circle) Male Female ADDRESS:______________________________________________________________________________________APT:_______________ CITY:______________________________________ ZIP:_____________ PARENT/GUARDIAN NAME:______________________________________________________ BIRTHDATE:___________________________ PHONE:____________________________________ EMAIL:_________________________________________________________________ PARENT/GUARDIAN NAME:_______________________________________________________ BIRTHDATE: __________________________ PHONE: ____________________________________EMAIL:_________________________________________________________________ IF CHILD IS IN FOSTER CARE: AGENCY NAME: _____________________________CASE WORKER:_________________________PHONE: __________________________ CHILD LIVES WITH: (Please Circle) Both Parents Mother Father Guardian(s) Other:____________________________________ Has your child attended any Early Childhood programs previously? Y / N ___If, Yes, for how many years: ___________________________ Please list any siblings enrolled in our Early Head Start / Head Start Programs: _________________________________________________ Please indicate below if any siblings attend CAS Schools, After School Programs, or any other CAS services: If any of your children are interested in CAS After School or other CAS programs, please also indicate below. OTHER FAMILY MEMBERS IN THE HOME: Name GENDER DOB RELATIONSHIP (To Child) CAS SERVICES 1. __________________________ ________ _________ ________________________ _____________________ 2. __________________________ ________ _________ ________________________ _____________________ 3. __________________________ ________ _________ ________________________ _____________________ 4. __________________________ ________ _________ ________________________ _____________________ 5. __________________________ ________ _________ ________________________ _____________________ 6. __________________________ ________ _________ ________________________ _____________________ Is there a court order that prohibits or restricts any person from contact with the child? No _____ Yes _____ If yes, please supply a copy of court order to Head Start staff. EARLY CHILDHOOD APPLICATION FORM Application # __________ THE FOLLOWING INFORMATION IS REQUESTED FOR STATISTICAL PURPOSES ONLY. CHECK ONLY ONE FOR EACH CATEGORY: ETHNICITY: _____ Hispanic or Latino Origin ____ Non-Hispanic/Non-Latino RACE: _____ Native American or Alaskan Native _____ Asian _____ Black or African American _____ Native Hawaiian or Other Pacific Islander _____ White _____ Bi-Racial or Multi-Racial _____ Other (Please Specify): _______________________________________ Is English the primary language spoken in the home? No _____ Yes _____ Is there a second language spoken in the home? No _____ Yes _____ What language? _____________________________ Is there a third language spoken in the home? No _____ Yes _____ What language? __________________________ Parent(s)/Guardian(s) Employment Status: Guardian 1: Full Time _______ Part Time_______ Unemployed_________ Occupation ____________________________________ Employer: _________________________________________________ Guardian 2: Full Time ________ Part Time_______ Unemployed_____ Occupation ____________________________________ Employer: _________________________________________________ (Full time employment is equal to 35 hours per week or more, year round Parent(s)/Guardian(s) Education Status: Mother Father Did not complete high school GED in progress GED received High School graduate Some college/Trade School graduate/Associate Degree College graduate (Bachelor’s degree or more) Are parent(s)/guardian(s) enrolled in an educational or job training program? Guardian 1: No______ Yes______ Where:_________________________________________________________________ Guardian 2: No______ Yes______ Where:_________________________________________________________________ 2 EARLY CHILDHOOD APPLICATION FORM Application # __________ HEAD START ELIGIBILITY (Not Applicable for UPK ): 1. Total Family Members: _____________ Total Annual Income: $________________ (Income Guideline Attached) 2. Is your child receiving special services (such as an IEP or IFSP)? No _____ Yes _____ If yes, please indicate the area of concern: ______________________________________________________________________ 3. Do you have any concerns about your child’s development? No _____ Yes _____ If yes, please indicate the area of concern: ______________________________________________________________________ Please check any additional criteria that apply: Homeless ______ Overcrowded Home ______ Domestic Violence ______ Teen Parent Foster Care ______ Cash Assistance ______ Imprisonment ______ Pregnant (EHS) ______ TANF Food Stamps ______ Military ______ Single Parent WIC ______ Returning Family ______ SSI ______ ______ ______ ______ HEALTH Is your child covered by health insurance? No _____ Yes _____ If yes, what insurance? Medicaid _____ Is your child covered by dental insurance? No _____ Yes _____ Child Health Plus (SCHIP) _____ Private Health Insurance _____ Other __________________ Private Dental Insurance _____ Does your child have a medical provider who provides regular medical care (for illness, well-child check ups, etc.)? No ____ Yes ____ Medical Provider: _______________________________________________________________________________________________ (Name) (Address) (Phone) Does your child have a dentist who provides regular dental care (check ups, treatment, etc.)? No _____ Yes _____ Dentist: _________________________________________________________________________________________________ (Name) (Address) (Phone) Do you have any health concerns about your child: Health (eg. asthma, recent hospitalization, other): __________________________________________________________________________ Dental (teeth): ___________________________________________________________________________________________________ Nutrition (allergies, appetite, cultural requirements): ________________________________________________________________________ Behavior (concerns or challenges)______________________________________________________________________________________ Other: __________________________________________________________________________________________________________ SIGNATURES: Parent Signature: _____________________________________________________________ Date: _________________ Staff Approval Signature: ______________________________________________________ Date: _________________ For Staff use only Eligibility Type (Head Start): ___ Income Eligible (20 ) ___ TANF / SSI / Public Assistance (10) ___ Foster Child (10) ___ Homeless (10) ___ Diagnosed Disability (10) ___ Overcrowded Home (5) ___ Imprisonment (5) ___ Military (5) ___ Teen Parent (5) ___ Suspected Disability (5) ___ Domestic Violence (5) ___ Single Parent (5) ___ Returning Family (5) TOTAL POINTS ________ 3 EARLY CHILDHOOD APPLICATION FORM Application # __________ 2016 FAMILY INCOME GUIDELINE EARLY HEAD START / HEAD START *Not Applicable for UPK Persons in family 100% Poverty Persons in family 100% Poverty 1 $11,880 5 $28,440 2 $16,020 6 $32,580 3 $20,160 7 $36,730 4 $24,300 8 $40,890 *For each additional person, add $4,160 4 EARLY CHILDHOOD APPLICATION FORM Application # __________ Directory (2 pages) HARLEM East Harlem Early Childhood PS 50 Early Childhood st 130 East 101 Street (btw. Lex & Park) 433 East 100th Street (btw 1s Ave & FDR Dr) New York, NY10029 New York, NY10029 Tel. 212-348-2343~ Fax. 212-876-0711 Jessica Napoleoni, Program Director Tel. 646-627-7449 ~ Fax. 212-860-2845 Tammy Moore, Program Director Frederick Douglass Early Childhood 885 Columbus Avenue at 104th Street Taft Early Childhood 1724-26 Madison Avenue at 114th Street New York, NY10025 Tel. 212-865-6337~ Fax. 212-961-0745 New York, NY 10029 Tel. 212-831-0556 ~ Fax. 212-426-0611 Jenny Bae, Program Director Beverly Largie, Program Director Drew Hamilton Early Childhood 2672 Frederick Douglass Blvd. at 142nd Street Milbank Early Childhood 14-32 West 118th Street (btw Lenox & 5th Ave) New York, NY10030 New York, NY 10026 Tel. 212-281-9555 Fax. 212-862-6161 Tel. 212-996-1716 Kirsy Mejia , Program Director Beverly Largie, Program Director Lilliana Jimenez, Family Coordinator WASHINGTON HEIGHTS PS 5 Early Childhood 3703 Tenth Avenue (btw. Dyckman & W. 201 St) New York, NY10034 PS 8 Early Childhood 465 West 167th Street at Amsterdam Ave New York, NY10032 Tel. 212-567-5787 ~ Fax. 212-567-2642 Tel. 212-740-8655 ~ Fax. 212-740-7420 Carmen Gonzalez, Education Director-EHS Marlene Aranda-Gillman, Program Director-EHS Tamara Royal, Education Director- HS Erica Quezada, Education Director - HS PS 152 Early Childhood 93 Nagle Avenue (btw Ellwood St & Sickles St) New York, NY10040 Tel. 212-544-0221 ~ Fax. 212-544-0244 Esther Olvera, Program Director 5 EARLY CHILDHOOD APPLICATION FORM Application # __________ Directory Continued. BRONX Bronx Early Childhood Program 1515 Southern Boulevard (btw. Jennings & E. 172nd) Bronx, NY10460 CS 211 Early Childhood Program 1919 Prospect Avenue Bronx, NY10457 Tel. 718-764-2409~ Fax. 718- 893-3664 Tel. 347-821-4222 ~ Fax. 718-893-3664 Shireen Hannam, Education Director Andrew Lindsay, Program Director CS 61 1550 Crotona Park East (btw. Charlotte St. & Suburban Pl.) Bronx, NY 10460 Tel. 718-991-2719 ext 2381/82 Carmen Miranda, Program Director STATEN ISLAND Richmond Early Learning Center 159 Broadway (btw Wayne St & Henderson Ave) Staten Island Family Services Center 465 Villa Avenue (btw Walker St. & Dixon Ave.) Staten Island, NY10310 Staten Island, NY 10302 Tel. 917-426-0300 ~ Fax. 718-447-4052 Tel. 718-448-1620 Geri Vignola, Program Director Yane Haro, Program Director CENTRAL OFFICE 4 West 125th St, 3rd Floor ~ New York, N.Y. 10027 ~ Fax (917) 286-1556 6 Moria Cappio - (o) 212-949-4930 (c) 646-280-7413 Andy Seltzer - (c) 347-574-5848 Antonio Freitas – (o) 917-286-1528 (c) 917-650-7980 Leslie Capello - (o) 212-949-4684 Simone Hawkins - (o) 212-901-1956 Adriana Alba - (o) 917-286-1529 Lysandra Agosto— (o) 917-286-1527 Johanna Cunningham—(o) 212-949-4931 EARLY CHILDHOOD APPLICATION FORM
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