PreK Counts Enrollment Application

PA PreK Counts Enrollment Form
Date

MonthDayYear
Date
Child's Name

First Name (Child)Middle InitialLast Name (Child)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County
City
Zip Code
School District of Residence
How did you hear about Kids First's PreK Counts program?
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Email Address
example@example.com
Child's Date of Birth

MonthDayYear
Date
Child's Age
Gender
Race (optional)
Ethnicity (optional)
Primary Language

Other
Name of Parent or Guardian completing this application
First and Last Name
Parent Gender
Relationship to Child

Other
Role

Other
Relation

Other
List Household Members below for determination of family size (required):
Household Member #2 Name
Full Name
Household Member #2 Age
Age
Household Member #3 Name
Full Name
Household Member #3 Age
Age
Household Member #4 Name
Full Name
Household Member #4 Age
Age
Household Member #5 Name
Full Name
Household Member #5 Age
Age
Household Member #6 Name
Full Name
Household Member #6 Age
Age
Household Member #7 Name
Full Name
Household Member #7 Age
Age
Household Member #8 Name
Full Name
Household Member #8 Age
Age
Employment Status of Parent/Guardian

Other
Employment Status of 2nd Parent/Guardian

Other
Household Income Sources (Must check all that apply)
Other Child Eligibility Risk Factor Criterion (Must check all that apply):

English Language Learner: Defined as a child whose first language is not English and who is in the process of learning English. Ask these two questions, as established by the Pennsylvania Department of Education, to determine if a child qualifies as an English language learner: 1) What is/was the child’s first language? 2) Does the child speak a language other than English?(Do not include languages learned in school).Homeless: If any of the situations below apply a family is eligible under McKinney-Vento. Additional guidance is available from the National Center for Homeless Education. 1. If the family is staying with others, was this a result of a loss of housing, economic hardship, or other similar reason? 2. Is the family living in a shelter? (Includes youth, emergency, transitional living, domestic violence, etc.) 3. Is the family living in a motel, hotel, or campground? 4. Is the family staying in a public or private place not ordinarily used as a regular sleeping accommodation for human beings? 5. Is the family living in cars, parks, public places, abandoned buildings, transportation stations, or similar settings? 6. Is the family living in substandard (limited or no utilities, unsafe conditions, etc.) housing? 7. Has the child been abandoned, in a hospital, or awaiting foster care placement?Migrant (Non-Immigrant)/Seasonal Student: Defined as a child who has moved from one school district to another to accompany or join a parent or guardian who is a migratory agriculture worker or 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, or work in nurseries such as Christmas and evergreen tree farming.
Income Documentation - W2 or Two Consecutive Paystubs for Anyone Bringing Home Income

Cancelof
Family Assurances
By signing below, I acknowledge and agree to the following:
Parent/Legal Guardian Certification
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 give proof of information provided.

I certify that all information provided is accurate. I understand that eligibility is subject to verification and providing false information may result in disqualification.
Parent/Guardian (Signature)
Date

MonthDayYear
Date
Parent/Guardian Name (Print Name)
Should be Empty:

PA PreK Counts Enrollment Form

Family Assurances

Parent/Legal Guardian Certification