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 or Most recent tax return 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 or 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

Application Date*
Program Year
Site Applying For:
- Ben Franklin Elementary, Uniontown
- Burchfield Primary School, Shaler Area SD, Pittsburgh
- Connellsville Township, Connellsville
- Donegal Elementary, Mt. Pleasant Area SD
- Greater Latrobe Elementary, Latrobe
- Lafayette Elementary, Uniontown
- Marshall Elementary, Uniontown
- Marzolf Primary School, Shaler Area SD, Pittsburgh
- Menallen Elementary, Uniontown
- Penn Hills High School, Penn Hills, Pittsburgh
- PIC Kidz Zone, Greensburg
- Reserve Primary School, Shaler Area SD, Pittsburgh
- Scott Primary, Shaler Area SD, Pittsburgh
- Southmoreland Elementary, Scottdale
- Springfield Twp. Elementary, Normalville
- Todd Lane Elementary, Monaca
- Wharton Elementary School, Farmington
Location subject to change
Child Information
First Name
Last Name
Middle Name
Preferred Name
Suffix
Date of BIrth
Gender
Race
- American Indian or Alaska Native
- Asian
- Black / African American
- Native Hawaiian
- Pacific Island
- White
Ethnicity
- Hispanic
- Non-Hispanic
- Unknown
English Proficiency
- None
- Poor
- Moderate
- Proficient
- Primary
Other Language Spoken
Other Language Proficiency
- None
- Poor
- Moderate
- Proficient
- Primary
Does this child have an active IEP or Behavior Plan?
- Yes
- No
IF YES, please upload a copy
Max. file size: 50 MB.
Check if you have any of the following concerns regrading your child:
- Speech
- Physical
- Vision
- Behavioral
- Health
- Developmental
- Hearing
Any additional explanation for above concerns please list here:
Have you ever applied with Pre-K Counts or Head Start for this child?
- Yes
- No
If YES, what year?
Is this child currently or has previously participated in the following?
- Head Start
- Early Head Start
- Early Intervention
Is this child in childcare / preschool?
- Yes
- No
If YES, where?
School district you live in
Home Elementary School
Agency Referral
Other Child Eligibility Risk Factors (Check all that apply)
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 may be required.
- Yes
- No
If yes above, please list the referring agency
Child Protective Services: A child who is a foster child, a kinship care child or receiving Children and Youth Services.
- Yes
- No
Education Level of Guardian: Parent or guardian does not have a high school diploma or GED
- Yes
- No
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.
- Yes
- No
Primary language (if other than English):
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.
- Yes
- No
Incarcerated Parent: A child for whom one of the child’s parents is currently in prison.
- Yes
- No
Homeless: A child who lacks a fixed, regular, and adequate nighttime residence due to one of the following: • 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; • 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; • Children who are living in cars, parks, public places, abandoned buildings, substandard housing, bus or train stations, or similar settings.
- Yes
- No
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 trees farming.
- Yes
- No
Teen Mother: A child whose mother was under the age of 18 when the child was born.
- Yes
- No
Child has none of the risk factors listed.
- Yes
- No
General Information - Primary Adult
Last Name*
First Name*
Middle
Suffix
Date of Birth*
Living Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
County*
Mailing Address (If different)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
County
Phone Number Type (home, work, cell) Primary? Notes
Number in Household*
Number in Family*
Total Number of Children*
Parental Status*
- One
- Two
Primary Language at Home*
- English
- Spanish
Family Income
Family Member Income Source Amount Per Annual Amount
If my child's application is determined to be eligible for Head Start, I give my permission for my information (contact, income, and birth certificate) to be shared with PIC's Head Start Program(s).*
- Yes
- No
Income Notes
Emergency Contacts
*
Name Relationship to Child Can release child to (Y/N) Address Phone 1 Phone 2 Notes
I certify that this information is true. If any part is false, my participation in this agency's programs may be terminated and I may be subject to legal action. I also understand that the information in this application will be held in strict confidence within the agency and is accessible to me during normal business hours*
- I understand
In lieu of a written signature, I acknowledge that by my checking the box below that it will be used in place of a signature as authorization to process this form and that a written signature still may be needed at a later date.*
- I Understand This is my Signature for this Form
Primary / Legal Guardian Adult
Last Name
First Name
Middle Name
Preferred Name
Gender
- Male
- Female
Date of Birth
Relationship to child
- Father
- Mother
- Grandparent
- Guardian
Race
- American Indian or Alaska Native
- Asian
- Black / African American
- Native Hawaiian
- Pacific Island
- White
Ethnicity
- Hispanic
- Non-Hispanic
- Unknown
Highest Grade Completed
Employment Status
- Full Time
- Part Time
- Retired or Disabled
- Training or in School
- Full Time and Training
- Part Time and Training
- Seasonally Employed
- Unemployed
Check all that apply
- Lives with this Family
- Provides Financial Support
- Teen Parent (18 yrs or younger)
- Incarcerated Parent
Email Address*
Secondary Adult
Last Name
First Name
Middle Name
Preferred Name
Gender
- Male
- Female
Date of Birth
Relationship to child
- Father
- Mother
- Grandparent
- Guardian
Race
- American Indian or Alaska Native
- Asian
- Black / African American
- Native Hawaiian
- Pacific Island
- White
Ethnicity
- Hispanic
- Non-Hispanic
- Unknown
Highest Grade Completed
Employment Status
- Full Time
- Part Time
- Retired or Disabled
- Training or in School
- Full Time and Training
- Part Time and Training
- Seasonally Employed
- Unemployed
Check all that apply
- Lives with this Family
- Provides Financial Support
- Teen Parent (18 yrs or younger)
- Incarcerated Parent
Email Address
Secondary Adult Living Address (If not living with Applicant)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
County
Other Family Members
Adult / Child Last First DOB Gender Relationship
Notes
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).
Primary Health Coverage Source
- Private
- CHIP
- None
- Unknown
- Medical Assistance
Immunizations Up-To Date?
- Yes
- No
Does your child have a physician he/she sees regularly?
- Yes
- No
Doctor Name
Is your child under the care of a physician?
- Yes
- No
If Yes, Why?
Does your child use the bathroom Independently?
- Yes
- No
If no, please explain:
Does your child have a dentist he / she sees regularly?
- Yes
- No
Dentist Name:
Is there a custody agreement regarding this child?
- Yes
- No
IF YES, please upload a copy of the custody agreement here:
Max. file size: 50 MB.
How did you hear about us?
- Word of Mouth
- Flyer / Brochure
- Yard Sign
- Radio
- Digital Billboard
Annual Household Income Documentation
Max. file size: 50 MB.
The following are included in determining annual income: a. Most recent W-2 Form or Most recent tax return 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.
Additional Income Documents (optional)
Max. file size: 50 MB.
Additional Income Documents (optional)
Max. file size: 50 MB.
Additional Income Documents (optional)
Max. file size: 50 MB.
Additional Verification Documents such as an IEP (optional)
Max. file size: 50 MB.
Copy of Child's Birth Certificate
Max. file size: 50 MB.
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Pre-K Online Application

PA Pre-K Counts Family Application

Child Information

Other Child Eligibility Risk Factors (Check all that apply)

General Information - Primary Adult

Family Income

Emergency Contacts

Primary / Legal Guardian Adult

Secondary Adult

Other Family Members

Disclaimer

Additional Info

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Phone Number	Type (home, work, cell)	Primary?	Notes

Family Member	Income Source	Amount	Per	Annual Amount

Name	Relationship to Child	Can release child to (Y/N)	Address	Phone 1	Phone 2	Notes

Adult / Child	Last	First	DOB	Gender	Relationship

Pre-K Online Application

PA Pre-K Counts Family Application

Child Information

Other Child Eligibility Risk Factors (Check all that apply)

General Information - Primary Adult

Family Income

Emergency Contacts

Primary / Legal Guardian Adult

Secondary Adult

Other Family Members

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