APPLICATION FOR COMMUNITY-BASED ORGANIZATION (CBO)

UNIVERSAL PRE-KINDERGARTEN (UPK)

FOR THE 2012 2013 SCHOOL YEAR

DIRECTIONS:
Please print clearly in blue or black ink only. Please note that only Parent/ Guardians who are New York City
residents may submit an application. Complete, sign and return this application directly to each CBO you wish
to apply to. Be sure to make a copy of the application and retain for your records. For a list of CBOs, please
review the Pre-kindergarten Directory available at your local school, CBO or online at
http://schools.nyc.gov/ChoicesEnrollment/PreK.

NAME OF CBO YOU ARE APPLYING TO:____________________________

Section A: STUDENT INFORMATION Please print clearly in ink
STUDENT LAST NAME STUDENT FIRST NAME DATE OF BIRTH (mm/ddyyyy) GENDER (optional)
/ / 2008
M F
STUDENT CURRENT ADDRESS (House #, Street, Apt. #, City, State and Zip Code)


Section B: OPTIONAL INFORMATION Please print clearly in ink
HEALTH INSURANCE
Does the student have health insurance?
Yes If yes, what type of coverage is it? Private Health Insurance Medicaid Child Health Plus B
No If no, would you like to be contacted about getting coverage? Yes No
HOME LANGUAGE
In which language(s) would you like to receive written and/or oral communication regarding the Pre-Kindergarten Admissions
Process? Please check all that apply: English Arabic Bengali Chinese Haitian Creole Korean Russian
Spanish Urdu Other, please specify: _____________________

Section C: PARENT INFORMATION Please print clearly in ink
I understand that daily attendance and promptness are required. I must arrange for a responsible adult to bring my child to
school and pick him/her up daily. I understand that no transportation is provided.
PARENT/GUARDIAN LAST NAME PARENT/GUARDIAN FIRST NAME RELATIONSHIP TO STUDENT
DAYTIME TELEPHONE NUMBER EVENING TELEPHONE NUMBER PARENT/GUARDIAN EMAIL ADDRESS
Parent/Guardian Signature Date


N.Y.
2014 - 2015
2010
Health CareProvider Name and Degree(print) Provider License No. and State
Facility Name National Provider Identifier (NPI)
Address City State Zip
CHILD & ADOLESCENT HEALTH EXAMINATION FORM
NYC DEPARTMENT OF HEALTH & MENTAL HYGIENE DEPARTMENT OF EDUCATION
TO BE COMPLETED BY PARENT OR GUARDIAN
Please
Print Clearly
Press Hard
STUDENT ID NUMBER
OSIS
Childs Last Name First Name Middle Name Sex 0 Female Date of Birth (Month/Day/Year )
Childs Address Hispanic/Latino?
0 Yes 0 No
0Male / /
Race (Check ALL that apply) 0 American Indian 0 Asian 0 Black 0 White
0Native Hawaiian/Pacific Islander 0Other
City/Borough State Zip Code School/Center/Camp Name District
Number
Phone Numbers
Home
Health insurance 0 Yes
(incl udi ng Medicaid)? 0 No
0 Parent/Guardian Last Name First Name
0 Foster Parent
Cell
Work
TO BE COMPLETED BY HEALTH CARE PROVIDER If yes to any item, please explain (attach addendum, if needed)
Birth hi story (age 0-6 yrs)
0 Uncomplicated 0 Premature: weeks gestation
Does the child/adolescent have a past or present medical history of the following?
0 Asthma (check severity and attach MAF/Asthma Action Plan): 0 Intermittent 0 Mild Persistent 0 Moderate Persistent 0 Severe Persistent
If persistent, check all current medication(s): 0 Inhaled corticosteriod 0 Other controller 0 Quickrelief med 0 Oral steroid 0 None
0Complicated by
0 Attention Deficit Hyperactivity Disorder 0 Orthopedic injury/disability
Medications (attach MAF if i n-school medi cati on needed)
All ergies 0 None 0 Epi pen prescribed
0Drugs (list)
0Foods (list)
0 Other (list)
0 Chronic or recurrent otitis media 0 Seizure disorder
0 Congenital or acquired heart disorder 0 Speech, hearing, or visual impairment
0 Developmental/learning problem 0 Tuberculosis (latent infection or disease)
0Diabetes (attach MAF) 0Other (specify)
0 None 0 Yes (list below)
Dietary Restri cti ons
0 None 0 Yes (list below)
PHYSICAL EXAMINATION
Height cm ( %ile)
Weight kg ( %ile)
BMI kg/m
2
( %ile)
Head Circumference (age 2 yrs) cm ( %ile)
Blood Pressure (age 3 yrs) /
Explai n all checked items above or on addendum
General Appearance:
Nl Abnl Nl Abnl Nl Abnl Nl Abnl Nl Abnl
0 0 HEENT 0 0 Lymph nodes 0 0 Abdomen 0 0 Skin 0 0 Psychosocial Development
0 0 Dental 0 0 Lungs 0 0 Genitourinary 0 0 Neurological 0 0 Language
0 0 Neck 0 0 Cardiovascular 0 0 Extremities 0 0 Back/spine 0 0 Behavioral
Describe abnormalities:
DEVELOPMENTAL (age 0-6 yrs) 0 Within normal limits SCREENING TESTS Date Done Resul ts
Date Done Resul ts
If delay suspected, specify below Blood Lead Level (BLL)
(required at age 1 yr and 2 yrs
/ / g/dL
Tubercul osi s Only required for students entering intermediate/middle/junior or high school
who have not previously attended any NYC public or private school
0 Cognitive (e.g., play skills) and for those at risk) / / g/dL
PPD/Mantoux placed / / Induration mm
Lead Risk Assessment
0 At risk (do BLL) PPD/Mantoux read / / 0 Neg 0 Pos
0 Communication/Language
(annually, age 6 mo-6 yrs)
Heari ng
/ / 0 Not at risk
Interferon Test / / 0 Neg 0 Pos
0 Social/Emotional
0 Pure tone audiometry 0 Normal
0 OAE / / 0 Abnormal
Chest x-ray 0 Nl 0 Not
0 Adaptive/Self-Help
Hemogl obi n or
Head Start Onl y
g/dL
(if PPD or Interferon positive)
Visi on
/ /
0 Abnl Indicated
Acuity Right /
0 Motor
Hematocri t (age 912 mo)
(required for new school entrants
/ / Left /
IMMUNIZATIONS DATES CIR Number
/ / % and children age 47 yrs)
0 with glasses Strabismus 0 No 0 Yes
of Child Influenza / / / / / /
Hep B / / / / / / / /
MMR / / / / / /
Rotavirus / / / / / /
Varicella / / / /
DTP/DTaP/DT / / / / / /
Td / / / / / /
/ / / / / /
Tdap / / Hep A / / / /
Hib / / / / / / / /
Meningococcal / / / /
PCV / / / / / / / /
HPV / / / / / /
Polio / / / / / / / /
Other, specify: / / ; / /
RECOMMENDATIONS 0 Full physical activity 0 Full diet
0 Restrictions (specify)
Follow-up Needed 0 No 0 Yes, for Appt. date: / /
Referral(s): 0 None 0 EarlyIntervention 0 Special Education 0 Dental 0 Vision
0Other
ASSESSMENT 0 Well Child (V20.2) 0 Diagnoses/Probl ems (list) ICD-9 Code
Health Care Provider Signature Date DOHMH PROVIDER
/ /
ONLY I.D.
TYPE OF EXAM: NAE Current NAE Prior Year(s)
Comments
Telephone Fax
Date
Reviewed:
/ /
I.D. NUMBER
( ) ( )
REVIEWER:
CH-205 (5/08) Copies: Whi te School/Child Care/Early Intervention/Camp, Canary Health Care Provider, Pi nk Parent/Guardian
2008
N.Y.
/ / 2010





































FORM
PSE
THE New York City DEPARTMENT OF EDUCATION
FEDERAL PARENT/GUARDIANSTUDENT ETHNIC &RACE IDENTIFICATION
To the Parent/Guardian:
Federal lawrequires the New York City Department of Education to collect and record the ethnic
identity and race of public school students. This information is used to determine funding for your
school, among other things, and is kept secure and confidential.
We need your help to accomplish this task. Please respond to the ethnicity and race identification
questions on the back of this page. The first question provides an opportunity for you to indicate
whether your child is of Hispanic, Latino, or Spanish origin; the second question provides an
opportunity for you to indicate your childs race(s). Please be sure to respond to both questions.
Students identified with more than race will be counted in the two or more races category.
Hispanic students of all races will be counted in the Hispanic category.
The New York City Department of Education understands the sensitive nature of this process.
The options provided by the federal government may not represent an accurate or complete
portrayal of your familys own ethnic or race identification. We encourage you to provide
responses using your best judgment. If you decline to respond to either question, federal
guidelines require New York City Department of Education school staff to make an identification
of your child on your behalf.
Race and ethnicity information for students is protected by the confidentiality regulations cited at
the bottom of this page.
Thank you for your cooperation.
PSE FORM08252010
Parents and Guardians: Please complete the form on the reverse
side of this page and return it to your childs school.
Confidentiality Procedures and Regulations
The Family Educational Rights and Privacy Act (1974) and Regulations of the Chancellor A-820 prohibit
unauthorized access to student records and unauthorized release of any student record information identifiable by
either student name or student identification number.
1
Race may be considered as a factor in school enrollment only where required by court order; gender is a factor
only in single-gender schools.
School staff: File the completed form in the students Cumulative
Record folder as confidential information.

1. Is the student Hispanic, Latino, or of Spanish origin? Hispanic, Latino, or of Spanish origin means a person of Cuban, Dominican, Mexican,
Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race.




YES, Hispanic



NO, not Hispanic
FORM
PSE
THE New York City DEPARTMENT OF EDUCATION
FEDERAL PARENT/GUARDIAN STUDENT ETHNIC & RACE IDENTIFICATION
- All students between 5 and 21 years of age have the right to a free public education.
- Federal law requires the New York City Department of Education to collect and record the ethnic
identity and race(s) of public school students.
- Children may not be refused admission to a public school because of race, color, creed, national
origin, gender, gender identity, pregnancy, immigration/citizenship status, disability, sexual
orientation, religion, or ethnicity.
1

English Only
SCHOOL STAFF: PLEASE COMPLETE THIS SECTION
Borough

District

School

Name of
High School/
Mini School /Annex
Grade Code

Class Code

NYC Student Identification Number

Date of Birth (Month/Day/Year)

(HIGH SCHOOL ONLY 4-DIGIT)
Student Name: Last, First, Middle Initial
PARENT/GUARDIAN: PLEASE COMPLETE THIS SECTION
PLEASE ANSWER BOTH QUESTIONS (1) AND (2). PLEASE READ THEM BEFORE YOU RESPOND.
For Question (1), check () the box that best describes your child.
For Question (2), check () all boxes that apply to your child.
2. Select one or more races from the following five racial groups.

























AMERICAN INDIAN OR ALASKAN NATIVE: A person having origins in any of the original peoples of North America and South America (including Central
America. (ATS Code: B)
ASIAN: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Sub-Continent including for example, Cambodia,
China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. (ATS Code: C)
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER: A person having origins in any of the original peoples of Hawaii, Guam, or other Pacific Islands. (ATS
Code: D)
BLACK: A person having origins in any of the Black racial groups of Africa. (ATS Code: E)
WHITE: A person having origins in any of the original peoples of Europe, North Africa, or the Middle East. (ATS Code: F)
Signature of Parent/Guardian/Other/School Staff Observer: Date:
Relationship to Student:
Parent Guardian Other (Specify):
See reverse side for an important message to parents/guardians and
for confidentiality procedures and regulations
School Staff Observer (Name):
-- ---
Residency Questionnaire





Parent/Guardian/Student:
This form is intended to address the McKinney-Vento Act 42 U.S.C. 11435, and must be completed for each
student. The information you provide is confidential. Your child will not be discriminated against based upon the
information provided.

Please complete the following questions regarding the students housing in order to help determine services the
student may be eligible to receive.

Note to schools/Temporary Housing Liaisons: Please assist students and families in filling out this form. Do not simply include
this form in the registration packet, because if the student qualifies as residing in temporary housing, the student is not required to submit
proof of residency and other required documents that may be part of the registration packet.
Please identify the students current living arrangements. Please check one box:












If the student is NOT living in permanent housing, also indicate if the below applies:


________________________________ _________________________________ ___________________
Parent/Guardian Name (print) Parent/Guardian Signature Date
Please return this form to your childs school as requested.




Note: The answer you give above will help determine what services you or your child may be eligible to receive under the McKinney-
Vento Act. Students who are protected under the Act are entitled to immediate enrollment in school even if they do not have the
documents normally needed, such as proof of residency, school records, immunization records, or birth certificate. After the student has
been enrolled, the new school must contact the last school attended to request the students educational records, including immunization
records, and Students in Temporary Housing (STH) Liaison(s) must help the student get any other necessary documents or
immunizations. Students who are protected under the McKinney-Vento Act may also be entitled to free transportation and other services.
Please refer to Chancellors Regulation A-780.
This form is accompanied by a one-page attachment titled,
McKinney-Vento Homeless Assistance Act Students in Temporary Housing Guide for Parents & Youth.
Revised 7/1/09
Student Name
Last First Middle


OSIS #
Date of Birth
MM/DD/YY
Gender School
Check
()
Residency Questionnaire Choice

ATS Code
Doubled-Up
With another family or other person because of loss of housing or as a result of economic hardship
D
Shelter
Emergency or transitional shelter
S
Awaiting Foster Care Placement A
Hotel / Motel
Living in what is NOT an emergency or transitional shelter and involves payment
H
Other Temporary Living Situation
Trailer park, campground, car, park, public places, abandoned building, street, or any other
inadequate living space
T
Permanent Housing
Student who is living in a fixed, regular, and adequate housing situation
P
Unaccompanied Youth
Youth who is not in the physical custody of a parent or guardian
Unac Youth
Enter Y if
applicable
School Use
Only
School Use
Only
/ / 2008
/ / 2010
Chancellors Regulation A-101
Attachment No. 3
Page 1 of 2
PARENT AFFIDAVIT OF RESIDENCY
In accordance with Chancellors Regulation A-101, if a parent is subletting an apartment or home, or if
more than one family shares a living space and there is only one leaseholder or homeowner, the parent
must present a notarized Address Affidavit signed both by the primary leaseholder as well as the parent
affirming that the family is residing in this home, and must attach the lease or deed.
Section A: STUDENT INFORMATION Please print clearly in ink
STUDENTS LAST NAME STUDENTS FIRST NAME GENDER (optional) M / F
DATE OF BIRTH (MM/DD/YY) OSIS #/STUDENTS ID #(if available) TELEPHONE #
STUDENTS CURRENT ADDRESS (House #, Street, Apt. #, City, State and Zip Code)
Section B: PARENT INFORMATION Please print clearly in ink
PARENT/GUARDIANS LAST NAME PARENT/GUARDIANS FIRST NAME
PARENT/GUARDIANS CURRENT ADDRESS (House #, Street, Apt. #, City, State and Zip Code)
HOME PHONE WORK PHONE CELL PHONE EMAIL ADDRESS
Section C: PRIMARY RESIDENT/TENANT INFORMATION Please print clearly in ink
PRIMARY RESIDENT/TENANTS LAST NAME PRIMARY RESIDENT/TENANTS FIRST NAME
PRIMARY RESIDENT/TENANTS CURRENT ADDRESS (House #, Street, Apt. #, City, State and Zip Code)
HOME PHONE WORK PHONE CELL PHONE EMAIL ADDRESS
RELATIONSHIP TO PARENT ANTICIPATED DURATION OF STAY
MALE FEMALE
2008
N.Y.
2010
Chancellors Regulation A-101
Attachment No. 3
Page 2 of 2
To be completed by the Parent:
I, _________________________________________, the parent of ___________________________________________,
(insert name and date of birth of student)
hereby affirm that I am residing with _____________________________________________________________________
(insert name)
at the following address ______________________________________________________________________________.
(insert address and contact number of primary leaseholder)
I understand that the New York City Department of Education has the right to conduct an Attendance Investigation to verify
my residence including a visit to the home of the primary leaseholder. I also understand that registration in school is based
on eligibility determined by my residence, and the Department of Education has the right to transfer students for whom
falsified documentation was provided at the time of registration.
In the event that my residency changes, I agree to notify my childs school and present new proof of address.
Parent Signature: _______________________________________________________
STATE OF NEW YORK
SS:
COUNTY OF
Sworn to before me this _______ day of _______________________, Year _________
Notary Public
To be completed by Primary Leaseholder/Tenant:
I hereby affirm that __________________________________________________________________________________
(insert name of parent and child/children)
are residing with me at _______________________________________________________________________________.
(insert address)
I understand that by signing this affidavit I am verifying the residence of ________________________________________.
(insert names)
I also understand that the New York City Department of Education has the right to conduct an Attendance Investigation to
verify the residence of the parties named in this affidavit, including a visit to my home and interviews with my neighbors. I
can be contacted at the number(s) listed below should the Department of Education require further information.
Primary Leaseholder Signature: ____________________________________________
STATE OF NEW YORK
SS:
COUNTY OF
Sworn to before me this _______ day of _______________________, Year _________
Notary Public
The New York City Department of Education
Pre-Kindergarten Language Needs Survey
1
Dear Parent or Guardian,
This survey is an important piece of your pre-kindergarten enrollment package as it provides your new
school with information about your familys language needs. Your assistance in answering the questions
below is greatly appreciated. Please return this form to your school administrator,
, and if you have questions, speak with at
.
Thank You


PART 1. LANGUAGE NEEDS: This information will establish what language is used at home and the language of
instruction requested by the family (if available).
1. Which language(s) do you speak at home? Please check () all that apply:

English
Spanish
Chinese
Bengali
Arabic
Haitian Creole
Russian
2.What language does the child understand?

Urdu
French
Korean
Albanian
Punjabi
Polish
Other, please specify

English Other Home Language(s) :

3. What language does the child speak?

English Other Home Language(s) :

4. What language does the child read?

English Other Home Language(s) : Does not read yet
5. What language does the child write?

English Other Home Language(s) : Does not write yet
6. What language is spoken in the childs home or residence most of the time?
English Other Home Language(s) :
7. What language does the child speak with parents/guardians most of the time?
English Other Home Language(s) :
8. What language does the child speak with brothers, sisters, or friends most of the time?

English Other Home Language(s) :

9. What language does the child speak with other relatives or caregivers (e.g., babysitters) most of the time?
English Other Home Language(s) :
10.Would you like your child to receive instruction using your home language (if available):

All the time Most of the time Some of the time
Does not read yet
Does not read yet
2
The New York City Department of Education
Pre-Kindergarten Language Needs Survey

PART 2. INSTRUCTIONAL PLANNING: Responses to these supplementary questions will be used for instructional
planning. Enter the correct response for each of the following questions concerning your child.
1. Is this your childs first time participating in an instructional program or group experience in the U.S.?

Yes No

IF NO:

a. Where did he/she go participate in daycare/preschool/play group?

b. What was the date of enrollment?

c. How long did he/she attend?

d. Which language was used for instruction?

2. Has your child participated in an instructional program or group experience in another country?

Yes No

IF YES:
a. Where did he/she participate in daycare/preschool/play group?
b. How long did he/she attend?
c. Which language was used for instruction?
3. Does your child have any conditions that require special help or attention in school? Yes No
IF YES, please check all that apply:
Hearing impaired
Visually impaired
Speech impaired
Physically impaired

Emotionally impaired
Asthma
Developmentally Disabled
Other (Please Specify)
IF YES, what early intervention has your child received, if any?

4. Does the child use any other form(s) of communication, such as American Sign Language or Augmentative
Communication Device (e.g., Communication Board-manual/electronic)? Yes No
IF YES: Which ones?


PART 3. PARENT INFORMATION: Responses to these supplementary questions will be used so that the NYC
Department of Education can communicate with you in the language of your choice.

1. What is your first language?
Parent/Guardian:
First language:

Parent/Guardian:
First language:

2. In what language would you like to receive written information from the school?

3. In what language would you prefer to communicate orally with school staff?



Parent Signature Date
3
The New York City Department of Education
Pre-Kindergarten Language Needs Survey




TO BE COMPLETED BY ENROLLMENT OR SCHOOL PERSONNEL ONLY
Date: Name of Student:
Borough District: School:
Gender: Ethnicity Code:
(form PSE):
Date of Birth:
Relationship of person providing information for survey (check one):
Mother Guardian
Father Other (specify):
If an interview is conducted, in what language is it conducted?
Is a translator/interpreter used?
Pre-K Home Language Code
Potential English Language Learner?
Instruction will be provided in:
English
Spanish
Other
Both English and the home language of


Office of Communications and Media Relations
52 Chambers Street, New York, NY 10007
Tel: 212.374.5141 Fax: 212.374.5584



CONSENT TO PHOTOGRAPH, FILM, OR VIDEOTAPE A STUDENT FOR NON-PROFIT USE
(e.g. educational, public service, or health awareness purposes)





Student Name: _________________________ School: _________________________



I hereby consent to the participation in interviews, the use of quotes, and the taking of photographs, movies or video tapes
of the Student named above by .
I also grant to the right to edit, use, and reuse said products for non-
profit purposes including use in print, on the internet, and all other forms of media. I also hereby release the New York
City Department of Education and its agents and employees from all claims, demands, and liabilities whatsoever in
connection with the above.




Signature of Parent/Guardian (if Student is under 18): _____________________________ Date: _______________

Address of Parent/Guardian: ________________________________________________________________________


OR


Signature of Student (if 18 or over): ____________________________________ Date: __________________

Address of Student: __________________________________________________________________________