Child must be 4 years old on or before December 1, 2017 and live in one of the following school districts to be eligible (Albany, Cohoes, Green Island, Lansingburgh,

Menands, North Colonie, South Colonie, Rensselaer, Troy, and Watervliet). Children eligible to attend Kindergarten are not eligible for UPK. The 5 hour a day, 5 day/week UPK Program is New York State

funded. Income is not a factor. All families are encouraged to apply. Transportation is not provided. Parents must provide transportation to and from the program daily.

Before Care and After Care are available. Date: _____________

Child’s Name: ______________________________________________

DOB: __________ Male/Female (circle one) School District child resides in: __________________

Parent/Guardian #1________________________ Parent/Guardian #2________________________ (Last) (First) (Middle) (Last) (First) (Middle)

Child’s Address: _____________________________________________________________

_____________________________________________________________

Telephone # Home: ______________Cell: ______________Work: ____________ Email: _________________________

Site Preference: Please rank your preference of location. Options include Maplewood School and Troy Boys and Girls Club. Note: If you reside in the Troy City School District, your default location may be the Troy Boys and Girls Club.

1st Choice: _____________________________________________

2nd Choice: ____________________________________________

Does the child receive Special Education Services? Yes No (please circle one)

Is English the primary language spoken in the home? Yes No (please circle one)

What other languages are spoken at home? _________________________________

• All questions above must be answered. Omitting or falsifying information will result in denial of admission. • Transportation is not provided. Parents must provide transportation to and from the program daily. • Please note that this application will only be accepted if we have a copy of the child’s birth certificate and proof of

residency. • You will be notified of acceptance. At that point registration will be finalized. • Please be aware at registration you will be required to provide a current physical and immunization record for the child. • If you are in need of assistance completing this application or future registration packet, please let us know and we will

be happy to assist you.

How did you hear about us? Please check one:

__Currently enrolled in Kids Express/Achievements __Website __Radio Advertisement __Newspaper Advertisement __PBS/Sesame Street Commercial

____________________________________________Signature

__School District name: _______________ __Family/Friend name: _______________ __Other: ___________________________

____________________________________________Date

Universal Pre-K (UPK) Program 2017-2018 Application

518-328-0430 518.782.1178