2024-25 PA Pre-K Counts Enrollment Form

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This information is confidential to the PA Pre-K Counts Program

Email *

Child's First Name *

Child's Last Name *

Child's Middle Initial

Street Address *

County *

City *

State *

Zip Code *

School District of Residence *

Home Phone *

Work Phone

Email Address *

Child's Date of Birth *

YYYY

Age *

Gender *

Male

Female

Race (optional)

Black or African American

Asian

Native Hawaiian or Pacific Islander

American Indian or Alaskan Native

White

Not Applicable

Other:

Ethnicity (optional)

Hispanic

Non-Hispanic

Not Applicable

Clear selection

Primary Language *

English

Spanish

Other:

Name of Parent or Guardian completing this application *

Your Gender *

Male

Female

Relationship to Child *

Father

Mother

Guardian

Other:

(select) *

Biological

Foster

Adoptive

Other:

Role *

Primary Guardian

Secondary Guardian

Legal Guardian

Other:

Household Members & Ages *

Please list all members of the household living with the child, including adults and the enrolling child, and their ages.

Ex. Jane Doe, 35; John Doe, 38; Billy Doe, 5

Employment Status of parent/guardian *

Full-time

Part-time

Unemployed

Other:

Employment Status of 2nd parent/guardian

Full time

Part time

Unemployed

Other:

Clear selection

Household Income Sources *

Employment

Self-Employment

Unemployment Compensation

Worker's Compensation

TANF Cash payments

Social Security

SSI

Child Support

Alimony

Other:

Required

Your total household income *

*If selected for Pre-K Counts, you must provide proof of household income

Other Risk Factors *

Behavioral Supports: A child who was referred 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; C. 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 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, working in nurseries such as Christmas and evergreen tree farming

Teen Mother: A child whose mother was under the age of 18 when the child was born.

None of the above apply.

Required

Parent/Guardian Name (Confirming Risk Factors) *

Date Completed (Confirming Risk Factors) *

YYYY

Consent to Electronic Signature
*

Forging or altering an electronic signature on this form is subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsifications to authorities.

I consent

Required

Parent/Guardian Signature *

Date Completed (Confirming Application Completion) *

YYYY

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