Success by 6 Online Application - Batavia United Way

Success by Six

Success by Six Application

If you are interested in preschool for your child but cannot afford the cost, please complete this application. Once you apply, a Batavia United Way team member will reach out to help coordinate a preschool that will fit your family’s needs.

Student First Name

Student Last Name

Student Date of Birth (Month/Day/Year)

Parent 1 First Name

Parent 1 Last Name

Parent 2 First Name

Parent 2 Last Name

Phone/Mobile (Parent 1)

Phone/Mobile (Parent 2)

Email (Parent 1)

Email (Parent 2)

Languages Child Speaks and Understands

Languages of Parent(s)

Is your child potty-trained?

Yes

In progress

Needs help using bathroom

School/Program Applying for (select all that apply)

Batavia Covenant Church Preschool

New Horizons Park District Preschool

Batavia United Methodist Parent's Day out

If available, which do you prefer?

2 Days per week

3 Days per week

4 Days per week

5 Days per week

Which time of day do you prefer?

Morning

Afternoon

Either morning or afternoon

Will you be able to provide transportation to and from the program AND in case of emergency?

Yes

Scholarship Eligibility Criteria: (Please each each line to agree with terms)

	Yes
My child is of preschool or kindergarten age.
My child lives in Batavia or the school boundaries established by Batavia Public Schools.
My family meets the income guidelines. (If not, please provide information in the applicant narrative.)
My family agrees to provide transportation to and from the program and is available to transport child in case of illness.
My family agrees to pay the established co-payment fee, if applicable.
My child will attend the program on a regular basis. Poor attendance may result in a loss of the scholarship.

APPLICANT NARRATIVE: Please tell us about your child. Are there any circumstances we should be aware of? If the application is for a unique request, explain the suggested program and goals hoped to achieve through intervention. If you do not qualify for Link/SNAP benefits, please provide information to help us determine financial eligibility.

Proof of Residency and Eligibility

Proof of residency and financial eligibility are required to complete your application.

For Residency, please submit a copy of your recent (within the past 30 days) rent or utility bill. Name, address, and date MUST be visible.

For Financial Eligibility we can accept a copy of your Link card and/or proof of Medicaid/KidCare. Name and date of eligibility must be included. If you do not have Link, BUW will work with you to determine if you qualify.

Please submit these items below or you may email to: successby6@bataviaunitedway.org or mail to the office at 700 W Fabyan Parkway, Suite 120A, Batavia IL 60510.

Your application will not be reviewed until all parts are received and complete. Once your application is received, a Batavia United Way representative will contact you to review your application.

Best time, day, and way (email, text) to contact you.

Upload a copy of your recent rent or utility bill

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Upload a copy of your Link card

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In signing this application, you agree to the terms of scholarship eligibility including proof of financial qualifications, co-payment requirements, and 85% or better program attendance. Family grants Batavia United Way permission to communicate with program providers.

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Date / Time

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Success by Six Application

Proof of Residency and Eligibility

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