2020 PA Pre-K Counts Enrollment Form

Third Street Alliance 41 N 3 St, Easton, PA
2020 PA Pre-K Counts Enrollment Form
(This information is confidential to the PA Pre-K Counts program)
Date Form Completed:
Date

Month Day Year
Date
Child's First Name
Middle Initial
Child's Last Name
Street Address
Address

Street Address

County

City

Postal / Zip Code
School District of Residence
Home Phone
Phone Number

Area Code Phone Number
Work Phone
Phone Number

Area Code Phone Number
Email Address
Email
example@example.com
Child’s Date of Birth
Date

Month Day Year
Date
Age
2 3 4 5
Gender
Male Female
Race (optional)
Black or African American Asian Native Hawaiian or Pacific Not Applicable American Indian or Alaskan White
Ethnicity (optional)
Hispanic Non-Hispanic Not Applicable
Primary Language
English Spanish
Legal Guardian Name Information
Name

First Name Last Name
Gender

Male Female
Relationship to Child

Father Mother Guardian
Biological Foster Adoptive
Role

Primary Guardian Secondary Guardian Legal Guardian
Household/Family Size

1 2 3 4 5 6 7 8
Yearly Household Income (required)

Less than $5,000 $5,001-$10,000 $10,001-$15,000 $15,001-$20,000 $20,001-$25,000 $25,001-$30,000 $30,001-$35,000 $35,001-$40,000 $40,001-$45,000 $45,001-$50,000 $50,001-$60,000 $60,001-$70,000 $70,001-$100,000 More than $100,000
2020 Federal Poverty Level Guidelines
Actual Annual Verified Gross Household (Family) Income:
$
I will send my household W-2 forms to the Pre-K Counts Coordinator by
Tanya Falero can be reached at:

tfalero@thirdstreetalliance.org
610 438 9429
Family income is at or below 300% of the federal poverty level (required risk factor Consider all sources of income. See Federal Poverty Level Guidelines relative to family size (must be verified prior to enrollment

Please include the date and the signature of parent or guardian and the staff person to document that any family who is Head Start income-eligible (100% of FPL or below) has been informed of their eligibility for Head Start.
Third Street Alliance 41 N 3 St, Easton, PA
Parent Signature
Signature

Clear
Date

Month Day Year
Date
Other Child Eligibility Risk Factor Criterion (must check all that apply)
Type a question

Behavioral Supports: A child who was referred to PA Pre-K Counts from an appropriately credentialed health or mental health practitioner who is not employed by the PA Pre-K Counts program; a child who is receiving mental health treatment. Additional verification beyond the interview is required. Child Protective Services: A child who is a foster child, a kinship care child or receiving Children and Youth services. Education Level of Guardian: Does not have high school diploma or GED or post-secondary degree. English Language Learner: A child whose first language is not English and who is in the process of learning English is considered an English Language Learner. Individualized Education Plan (IEP): A child who is currently enrolled in the Preschool Early Intervention program with an active IEP. Verification would be a copy of the IEP or other source of documentation from the parent or Early Intervention provider. Incarcerated Parent: A child for whom one of the child’s parents is currently in prison Homeless: A child who lacks a fixed, regular, and adequate nighttime residence due to one of the following: A.Children who are sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason; are living in motels, hotels, or camping grounds due to lack of alternate accommodations; are living in emergency or transitional shelters; are abandoned in hospitals; or are awaiting foster care placement; B. Children who have a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings; C. Children who are living in cars, parks, public places, abandoned buildings, substandard housing,bus or train stations, or similar settings. Migrant(Non-Immigrant)/Seasonal Student: A migrant child has moved from one school district to another in order to accompany or to join a migrant parent or guardian, who is a migratory worker or migratory fisher, within the preceding 36 months, in order to obtain temporary or seasonal employment in qualifying agricultural or fishing work including agri-related businesses such as meat or vegetable processing, working in nurseries such as Christmas and evergreen trees farming. Teen Mother: A child whose mother was under the age of 18 when the child was born.

2020 PA Pre-K Counts Enrollment Form

Date Form Completed:

Street Address

Home Phone

Work Phone

Email Address

Child’s Date of Birth

Age

Gender

Race (optional)

Ethnicity (optional)

Primary Language

Legal Guardian Name Information

2020 Federal Poverty Level Guidelines

Actual Annual Verified Gross Household (Family) Income:

Parent Signature

Other Child Eligibility Risk Factor Criterion (must check all that apply)