Pre-K Counts Application - English
2025-2026
Name
*
First Name
Last Name
Address
*
Street Address
County
City
State / Province
Postal / Zip Code
Home Phone
*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
School District
Email
*
example@example.com
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Age at the start of the Program year
*
3 years old
4 years old
5 years old
Gender
*
Male
Female
Race (optional)
Black or African American
Asian
Native Hawaiian or Pacific Islander
White
American Indian or Alaskan Native
Other
Ethnicity (Optional)
Hispanic
Non-Hispanic
Not applicable
Primary Language
*
English
Spanish
Other
Primary Guardian Name
*
First Name
Last Name
Parent Gender
Male
Female
Relationship to Child
*
Please Select
Father
Mother
Guardian
Other
Relationship to child continued
*
Please Select
Biological
Foster
Adoptive
Role
*
Please Select
Primary Guardian
Secondary Guardian
Biological Guardian
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List Household Members below for determination of family size (required):
*
Name
Relationship to child
Age
1 Enrolling Child
2
3
4
5
6
7
Who is a family member?
Per PKC Statute, Regulations, and Guidance, the following members of the household are included in family size: A. Parent of the child (biological or adoptive mother or father, stepmother or stepfather, caretaker or spouse) B. A biological, adoptive, unrelated or foster child or stepchild of the parent or caretaker who is under 18 years of age and not emancipated. C. 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. D. 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.
Determined Family Size =
*
Employment status of Parent/guardian
*
Please Select
Full-time Employment
Part-Time Employment
Unemployed
Other
Employment Status of 2nd parent/guardian
Please Select
Full-time Employment
Part-time Employment
Unemployed
Other
Household Income Sources (Must check all that apply):
*
Employment
Self-Employment
Social Security
SSI
Unemployment Compensation
Worker's Compensation
TANF Cash payments
Child Support
Alimony
Other
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Other Child Eligibility Risk Factor Criterion (Must check all that apply):
Risk Factor
Preschooler with an Individualized Education Program (IEP)-
Defined as a child who is
currently enrolled in the Early Intervention program with an active IEP.
Verification includes a copy of the IEP or other source of documentation from
the parent or the Early Intervention agency.
Migratory (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.
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. - If the family is staying with others, was this a result of a loss of housing, economic hardship, or other similar reason? - Is the family living in a shelter? (Includes youth, emergency, transitional living, domestic violence, etc.) - Is the family living in a motel, hotel, or campground? - Is the family staying in a public or private place not ordinarily used as a regular sleeping accommodation for human beings? - Is the family living in cars, parks, public places, abandoned buildings, transportation stations, or similar settings? - Is the family living in substandard (limited or no utilities, unsafe conditions, etc.) housing? - Has the child been abandoned, in a hospital, or awaiting foster care placement?
Child in or Part of Family in Child Welfare System - Defined as a child who is a foster child, a kinship care child, or receiving Children and Youth Services
Child’s Family or Living Structure - Defined as a child with a single parent, divorced parents, or with relatives as guardians.
Child Receiving Behavioral Supports - Defined as a child who is referred to Pennsylvania Pre-K Counts from an appropriately credentialed health or mental health provider (not employed by the Pennsylvania Pre-K Counts program) or a child who is receiving mental health treatment. Additional verification beyond the interview is required
Teen Parent - Defined as a mother or father who was under the age of 18 when the child was born
Incarcerated Parent - Defined as a child for whom one or both of the child’s parents are currently incarcerated.
Other Child Eligibility Risk Factor Criterion (Must check all that apply):
Risk Factors
Education Level of Guardian - Defined as when the parent or legal guardian of the child does not have a high school diploma, high school equivalency, or postsecondary degree.
Eligible for or Receives the Following Public Assistance: TANF, SSI, SNAP - This risk factor was added in 2024. Defined as a family who can produce documentation of eligibility for or receipt of TANF, SSI, or SNAP. (Categorically eligible for Head Start, please refer to HS program if available.)
Child Enrolled in Infant Toddler Contracted Slots Program (ITCSP) - Defined as a child enrolled in ITCSP and eligible to transition into PA PKC.
Child Lives in Geographic Area of High Poverty -
Providers wishing to prioritize specific geographic regions with higher rates of poverty may do so. This might include specific zip codes, school districts, or other factors
Concerns Regarding Child’s Physical Development or Existing Medical
Condition (Currently Not Receiving EI Services) -
If a family concern is shared that is not covered by any of the other risk factors and the child has not yet been referred to EI for evaluation, the
program should share information on EI
Concerns Regarding Child’s Speech or Language Development (Currently Not Receiving EI Services) -
If a family concern is shared that is not covered by any other risk factors and the child has not yet been referred to EI for evaluation, the program should share information on EI.
Concerns Regarding Child’s Social, Emotional, or Behavioral Development
(Currently Not Receiving EI Services) -
If a family concern is shared that is not covered by any other risk factors and the child has not yet been referred to EI for evaluation, the program should share information on EI.
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Family Assurances By signing below, I acknowledge and agree to the following:
I understand that my child’s eligibility for Pennsylvania Pre-K Counts (PA PKC) is subject to the program’s two-year participation limit. My child must be at least three years old by the kindergarten cutoff date set by the school district where we live to assure compliance with receiving only two-years of PKC programming.
Once my child reaches the age required to enroll in kindergarten in the public school district where we live, I understand they will no longer be eligible for PA PKC funding.
I understand that my child’s enrollment is contingent upon meeting the eligibility criteria, including income verification and prioritization based on risk factors.
I understand that the PA Pre-K Counts (PKC)program is an educational program with attendance requirements. I agree to ensure my child’s regular attendance and to notify the program in case of absences. My program’s PA Pre-K Counts hours of operation are: 8:30am - 3:00pm
I understand that the PKCportion of the day will be secular (non-religious) in nature and will not include religious instruction during the PKC portion of the day. My program’s PA Pre-K Counts hours of operation are: 8:30am-3:00pm
I understand that once an enrollment start date is confirmed, the child’s PA Pre-K Counts enrollment status may be shared with other OCDEL-funded programs, such as the Early Learning Resource Center (ELRC) or Early Intervention, to ensure proper coordination of funding and services.
Parent/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.
First Name
Last Name
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Family and Program Administrator to Complete This Portion Together For Head Start Eligible families (100% of FPL or below). I have been informed of my child’s eligibility for Head Start and given the following:
*
Check if not applicable
Contact information for the following Head Start location: CAP LANCASTER
Application and/or assistance with referral
Brochure or Website information about Head start
I understand that my signature below indicates that I have been informed about my options for Head Start, and that I may choose to enroll in either the Pre-K Counts program or Head Start if eligible for both
Date
*
-
Month
-
Day
Year
Date
Please upload income verification here for your household (Income Tax Return, 1 month of Paystubs, SSI statement, etc.). Please email program director if you would rather bring forms into the center to submit in person.
*
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