• 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:

  •  -  -
    Pick a Date
  • Street Address

  • Home Phone

  •  -
  • Work Phone

  •  -
  • Email Address

  • Child’s Date of Birth

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    Pick a Date
  • Age

  • Gender

  • Race (optional)


  • Ethnicity (optional)

  • Primary Language


  • Legal Guardian Name Information





  • 2020 Federal Poverty Level Guidelines

  • Actual Annual Verified Gross Household (Family) Income:

  • 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

  • Clear
  •  -  -
    Pick a Date
  • Other Child Eligibility Risk Factor Criterion (must check all that apply)

  • Clear
  •  -  -
    Pick a Date
  •  
  • Should be Empty: