Pre-K Online Application

Application Date*

Program Year

Site Applying For:

Ben Franklin Elementary, Uniontown
Burchfield Primary School, Shaler Area SD, Pittsburgh
Connellsville Township, Connellsville
Frock Childcare Learning Center, Mt. Pleasant
Greater Latrobe Elementary, Latrobe
Hopwood Child Care, Hopwood
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

Other Language Spoken

Other Language Proficiency

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:

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

Primary / Legal Guardian Adult

First Name*

Middle

Last Name*

Suffix

Preferred Name

Date of Birth*

Gender

Male
Female

Relationship to child*

Check all that apply

Lives with this Family
Provides Financial Support
Incarcerated Parent

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

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

Email Address*

Secondary Adult

First Name

Middle Name

Last Name

Preferred Name

Date of Birth

Gender

Male
Female

Relationship to child

Check all that apply

Lives with this Family
Provides Financial Support
Incarcerated Parent

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

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

Email Address

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

Secondary Adult Living Address (If not living with Applicant)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

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

Income Notes

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

Emergency Contacts

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

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

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?*

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

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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Email

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PA Pre-K Counts Family Application

Child Information

Other Child Eligibility Risk Factors (Check all that apply)

Primary / Legal Guardian Adult

Secondary Adult

Family Income

Emergency Contacts

Other Family Members

Disclaimer

Additional Info

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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)

Primary / Legal Guardian Adult

Secondary Adult

Family Income

Emergency Contacts

Other Family Members

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