Pre-K Counts Registration Form

Pre-K Counts Registration Form

Lewisburg Area School District
Child's Name*

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Age at the Start of Program*
Gender*
Race (optional)
Ethnicity (optional)
Primary Language*
Parent/Guardian Name*

First NameLast NameSuffix
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone*
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
E-mail*
example@example.com
Gender*
Relationship to Child*
Type of Relationship*
Role*

List household members below for determination of family size (required):*

Rows	Full Name	Relationship	Age
1
2
3
4
5
6
7

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)
- 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.

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 8:45AM-3:30PM.
- I understand that the PKC portion of the day will be secular (non-religious) in nature and will not include religious instruction during the PKC portion of the day.
- 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.
Signature*
Should be Empty:

Pre-K Counts Registration Form

Employment and Risk Factors