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