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:

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



Household Family Size:



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