2021 2022 PA Pre-K Counts Enrollment Application
Date Form Completed
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Month
-
Day
Year
Date
Name
First Name
Middle Initial
Last Name
Address
Street Address
County
City
State / Province
Postal / Zip Code
School District of Residence
School District
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Child's Date of Birth
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Month
-
Day
Year
Date
Child's Age
2
3
4
5
Child's Gender
Male
Female
Race (optional)
Black or African American
Asian
Native Hawaiian or Pacific Islander
Not Applicable
American Indian or Alaskan Native
White
Other
Ethnicity
Hispanic
Non-Hispanic
Not Applicable
Primary Language
English
Spanish
Other
Name of Parent or Guardian completing this application
First Name
Last Name
Gender
Male
Female
Relationship to Child
Father
Mother
Guardian
Other
(Select)
Biological
Foster
Adoptive
Other
Role
Primary Guardian
Secondary Guardian
Legal Guardian
Other
List Household Members Below For Determination Of Family Size
Required. List Relationship to child and their age. Per PKC Statute, Regulations, and Guidance, the following members of the household are included in family size: ·Parent of the child (biological or adoptive mother or father, stepmother or stepfather, caretaker or spouse). A biological, adoptive, unrelated or foster child or stepchild of the parent or caretaker who is under 18 years of age and not emancipated. A child who is 18 years of age or older but under 22 years of age who is enrolled in high school, a general educational development program, or a post-secondary program leading to a degree, diploma or certificate and who is wholly or partially dependent on the income of the parent or caretaker or spouse of the parent or caretaker. Others supported by the income of the parent(s) or guardian(s) of the child enrolling or participating in the program. If counted toward family size, any applicable income of these persons must also be counted for eligibility purposes. Note: A family size value of one (1) with an income of $0 is entered when a foster child is applying for Pennsylvania Pre-K Counts
Age of Enrolling Child
Person 1
Person 1 Age
Person 2
Person 2 Age
Person 3
Person 3 Age
Person 4
Person 4 age
Person 5
Person 5 age
Person 6
Person 6 age
Person 7
Person 7 age
Employment Status of parent/guardian
Employed Full-Time
Employed Part-Time
Unemployed
Other
Employment Status of 2nd parent/guardian (if applicable)
Employed Full-Time
Employed Part-Time
Unemployed
Other
Household Income Sources (must check all that apply)
Employment
Self-Employed
Unemployment Compensation
Worker's Compensation
TANF Cash payments
Social Security
SSI
Child Support
Alimony
Other
Other Child Eligibility Risk Faction Criterion
Check All That Apply
Type a question
Behavioral Supports: A child who wa sreferred 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; 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 preceding36 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.
To the best of my knowledge, the information provided in this application and the associated income documentation is accurate. I understand that I may be asked to verify or substantiate information provided.
Parent/Guardian (Signature)
Clear
Parent/Guardian Name (Print)
Date
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Month
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Day
Year
Date
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