2017 PA Pre-K Counts Enrollment Form
Required Fields (*) (This information is confidential to the PA Pre-K Counts program)
* Last Name (Child): First Name (Child): Middle Initial:
*Address: *County:
*City: * * Zip code:
* School District of Residence:    
*  Home Phone: Work Phone: Email:
* Child's Date of Birth:  
Age:   Gender:  
Race (optional):





 
Ethnicity (optional):

   
Primary Language:

Other, specify:
   

Parent/Guardian #1
* Last Name (Legal Guardian): First Name: Gender:
        
Relationship to Child:


Other, specify:
Select:


Other, specify:
        
Role:


Other, specify:
   
        
Parent/Guardian #2
* Last Name (Legal Guardian): First Name: Gender:
        
Relationship to Child:


Other, specify:
Select:


Other, specify:
        
Role:


Other, specify:
   


Household Family Size:    
       
If this is a two parent/guardian household, 12 months of income from both parents/guardians MUST be submitted with this application.


Household Income (required) check box:











2017 Federal Poverty Level Guidelines

300%

Family Size

Annual

Monthly

Weekly

1

$36,180

$3,015

$696

2

$48,720

$4,060

$937

3

$61,260

$5,105

$1,178

4

$73,800

$6,150

$1,419

5

$86,340

$7,195

$1,660

6

$98,880

$8,240

$1,901

7

$111,420

$9,285

$2,142

8

$123,960

$10,330

$2,383

Each Add’l

$12,540

$1,045

$241


Actual Annual Verified Gross Household (Family) Income:



* I am interested in enrollment at one of the following centers:


Other Child Eligibility Risk Factor Criterion (Must check all that apply):











To the best of my knowledge, the information provided is accurate. I understand that I may be asked to verify or substantiate information provided.
* Parent/Guardian Signature (Please type full name): Date:  5/28/2017