Pre-K Online Application

Dear Parent/Guardian:
Thank you for your interest in the PA Pre-K Counts program. Please return your completed
application along with copies of the following: Please only send copies.
1. Your annual household income
2. Your child’s birth certificate

According to program regulations, annual household income (earned and unearned) is
required to establish eligibility.

The following are included in determining annual income:
a. Most recent W-2 Form (2019) or Most recent tax return (2019) or Pay stubs (last 30 days)
b. Unemployment Financial Determination Letter
c. SSI/Social Security Financial Award Letter
d. Child Support Information documenting (SCDU stub 0or court order) amount
received monthly
e. Unearned income including cash and contributions, dividends, interest, net income,
net royalties and periodic receipts from estates or trusts.
Please return your completed application to the Private Industry Council / attention Pre-K
Counts. Please note the gray shaded areas on the application are for agency staff only.

Private Industry Council / Pre-K Counts
112 Commonwealth Drive
Lemont Furnace, PA 15456
For questions call: 724-437-2590

Sincerely,
Pre-K Counts Staff

PA Pre-K Counts Family Application

  • General Information - Primary Adult

  • Phone NumberType (home, work, cell)Primary?Notes 
  • Family Income

  • Family MemberIncome SourceAmountPerAnnual Amount 
  • Emergency Contacts

  • NameRelationship to ChildCan release child to (Y/N)AddressPhone 1Phone 2Notes 
  • Primary / Legal Guardian Adult

  • Secondary Adult

  • Other Family Members

  • Adult / ChildLastFirstDOBGenderRelationship 
  • NOTICE: “All meals served to children under the Child Care Food Program are served at no separate charge regardless of race, color, sex, age, handicap, or national origin. There is no discrimination in admissions policy, meal service, or use of facilities. “Any complaints of discrimination should be submitted in writing within 180 days, of the incident to the Secretary of Agriculture, Washington, DC 20250.” Information from this application will be used for ongoing reporting/monitoring and assessment on a secured web-based system that is shared with multiple agencies (i.e. OCDEL, Head Start, CCIS, Early Intervention and other divisions within the Private Industry Council of Westmoreland/Fayette Inc).
  • Child Information

    Location subject to change
  • Max. file size: 50 MB.
  • Max. file size: 50 MB.
  • Max. file size: 50 MB.
    The following are included in determining annual income: a. Most recent W-2 Form (2019) or Most recent tax return (2019) or Pay stubs (last 30 days) b. Unemployment Financial Determination Letter c. SSI/Social Security Financial Award Letter d. Child Support Information documenting (SCDU stub 0or court order) amount received monthly e. Unearned income including cash and contributions, dividends, interest, net income, net royalties and periodic receipts from estates or trusts.
  • Max. file size: 50 MB.
  • Max. file size: 50 MB.
  • Max. file size: 50 MB.
  • Max. file size: 50 MB.