Pre-K Counts Enrollment

Step 1 of 3

33%

Name

This field is for validation purposes and should be left unchanged.

Household Income Sources / Fuente del Ingreso Familiar

Who contributes to the household income? / ¿Quien contribuye al ingreso familiar?

Annual Household Income / Cuales son sus Ingresos al Año

Family Size / Tamaño de la Familia

Name, Ages and Relationship to child of all people living in the house / Favor de escribir nombre, edad y relacion con el niño de todas las personas que viven en su casa

1. Name of Primary Parent/ Head of Household / Nombre del Padre Primario

Employment Status of Primary Parent/Guardian / Cual es el estatus laboral del padre primario

Did you file a 2025 Income Tax Return/ ¿Presento la declaración de impuestos de 2025?

Yes/Si

No/No

Proof of income: please upload the first page of your LAST Income Tax Return (If you don't have one, write a note and upload the note) / Comprobante de Ingresos: Favor de adjuntar la primera pagina DE SU ULTIMO reporte de Impuestos (si no tiene este documento, escriba una nota y subala al sistema)

Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 1 GB.

If you didn't have Income Tax return or if your income changed significantly, please upload a w2 or a recent paystub. If unemployed, please provide proof of any source of income. (ex: letter of child support, SSI award letter, CASH assistance, etc.)

Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 1 GB.

Please check which eligibility factor applies to your child or family / Seleccionar que factor de eligibilidad aplica para su hijo(a) o familia:

Child's Family or Living Structure: Single Parent.

Child's Family or Living Structure: Divorced Parents.

Child's Family or Living Structure: Relatives as Guardians. (Child doesn't live with mom or dad)

Teen Mother: A child whose mother was under the age of 18 when the child was born.

Concerns regarding Child's Physical Development or Existing Medical Condition (Currently not receiving EI Services)

Concerns regarding child's speech or Language Development (Currently not receiving EI Services)

Concerns regarding Child's Social, Emotional or Behavioral Development.

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 beyond the interview is required.

Child in or Part of Family in Child Welfare System: A child who is a foster child, a kinship care child or receiving Children and Youth services.

Education Level of Guardian: Does not have high school diploma or GED or post-secondary degree.

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.

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.

Incarcerated Parent: A child for whom one of the child’s parents is currently in prison.

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.

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.

Eligible for or Receives the Following Public Assistance: TANF, SSI, SNAP. Defined as a family who can produce documentation of eligibility for or receipt of TANF, SSI, or SNAP.

Child Enrolled in Infant Toddler Contracted Slots Program (ITCSP) and eligible to transition into PA PKC.

Child lives in geographic area of high poverty.

Contact's Information

Contact Name and Last Name /Nombre y Apellido:

First Last

Relationship to Child/Parentezco con el niño(a):

Preferred Language

Cell-Phone / Telefono Celular

Email/Correo Electronico

Home Address (Street, Number, City, State, Postal Code)/ Dirección de casa (Calle, Numero, Ciudad, Estado, Codigo Postal):

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

Child's Information

Child's Name

First Last

Gender

Birthday

MM slash DD slash YYYY

Age

Please enter a number from 2 to 5.

Important: Children that are 3 years old by September 1st, 2026 will begin 2026-2027 school year, If your child turns 3 after September 1st he/she will remain in our waiting list to start on 2027-2028 school year

I acknowledge

Allergies (Including Medication Reaction)/Alergias (Incluya medicamentos)

Does your child have a differing need? / Necesidades Diferentes

Is your child potty trained?/ Su hijo usa el baño?

By submitting this form, you acknowledge that you have read and agree to Day Nursery's privacy policy, and you authorize them to use your information as outlined in the policy.

I acknowledge

I have read and agree to Day Nursery’s Privacy Policy, and I authorize Day Nursery to use my information as described in the policy.

I acknowledge

I understand this form is the first step in the enrollment process and does not guarantee a spot in the 2026–2027 Pre-K program. I understand I will receive an email invitation to attend an Open House with next steps within 48 hours, and if I do not hear from Day Nursery, I will contact them.

I acknowledge

Click Here to read our Privacy Policy

2025-2026 PA Pre-K Counts Enrollment Form

Contact's Information

Child's Information