2025-26 PA Pre-K Counts Enrollment Form

Name(Required)
Address(Required)
MM slash DD slash YYYY
Age at start of program year:(Required)
Gender(Required)
Race (optional)
Ethnicity (optional)
Primary Language

Name of Parent or Guardian completing this application
Gender(Required)
Relationship to Child

Relationship Type

Role

List Household Members below for determination of family size (required):
1. Name
Please enter a number from 1 to 100.
2. Name
Please enter a number from 1 to 100.
3. Name
Please enter a number from 1 to 100.
4. Name
Please enter a number from 1 to 100.
5. Name
Please enter a number from 1 to 100.
6. Name
Please enter a number from 1 to 100.
7. Name
Please enter a number from 1 to 100.
8. Name
Please enter a number from 1 to 100.
9. Name
Please enter a number from 1 to 100.
10. Name
Please enter a number from 1 to 100.
Per PKC Statute, Regulations, and Guidance, the following members of the household are included in family size:
  • Parent of the child (biological or adoptive mother or father, stepmother or stepfather, caretaker or spouse)
  • A biological, adoptive, unrelated or foster child or stepchild of the parent or caretaker who is under 18 years of age and not emancipated.
  • A child who is 18 years of age or older but under 22 years of age who is enrolled in high school, a general educational development program, or a post-secondary program leading to a degree, diploma or certificate and who is wholly or partially dependent on the income of the parent or caretaker or spouse of the parent or caretaker.
  • Others supported by the income of the parent(s) or guardian(s) of the child enrolling or participating in the program. If counted toward family size, any applicable income of these persons must also be counted for eligibility purposes.
Note: A family size value of one (1) with an income of $0 is entered when a foster child is applying for Pennsylvania Pre-K Counts.
Please enter a number from 1 to 20.
Employment Status of parent/guardian

Employment Status of 2nd parent/guardian (if applicable

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

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

Risk Factor 1
Defined as a child who is currently enrolled in the Early Intervention program with an active IEP. Verification includes a copy of the IEP or other source of documentation from the parent or the Early Intervention agency.
Risk Factor 2
Defined as a child who has moved from one school district to another to accompany or join a parent or guardian who is a migratory agriculture worker or 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, or work in nurseries such as Christmas and evergreen tree farming.
Risk Factor 3
Defined as a child whose first language is not English and who is in the process of learning English. Ask these two questions, as established by the Pennsylvania Department of Education, to determine if a child qualifies as an English language learner: 1) What is/was the child’s first language? 2) Does the child speak a language other than English? (Do not include languages learned in school).
Risk Factor 4
If any of the situations below apply a family is eligible under McKinney-Vento. Additional guidance is available from the National Center for Homeless Education.
  • If the family is staying with others, was this a result of a loss of housing, economic hardship, or other similar reason?
  • Is the family living in a shelter? (Includes youth, emergency, transitional living, domestic violence, etc.)
  • Is the family living in a motel, hotel, or campground?
  • Is the family staying in a public or private place not ordinarily used as a regular sleeping accommodation for human beings?
  • Is the family living in cars, parks, public places, abandoned buildings, transportation stations, or similar settings?
  • Is the family living in substandard (limited or no utilities, unsafe conditions, etc.) housing?
Risk Factor 5
Defined as a child who is a foster child, a kinship care child, or receiving Children and Youth Services.
Risk Factor 6
Defined as a child with a single parent, divorced parents, or with relatives as guardians.
Risk Factor 7
Defined as a child who is referred to Pennsylvania Pre-K Counts from an appropriately credentialed health or mental health provider (not employed by the Pennsylvania Pre-K Counts program) or a child who is receiving mental health treatment. Additional verification beyond the interview is required.
Risk Factor 8
Defined as a mother or father who was under the age of 18 when the child was born. Defined as a mother or father who was under the age of 18 when the child was born.
Risk Factor 9
Defined as a mother or father who was under the age of 18 when the child was born. Defined as a mother or father who was under the age of 18 when the child was born.
Risk Factor 10
Defined as when the parent or legal guardian of the child does not have a high school diploma, high school equivalency, or postsecondary degree.
Risk Factor 11
This risk factor was added in 2024. Defined as a family who can produce documentation of eligibility for or receipt of TANF, SSI, or SNAP. (Categorically eligible for Head Start, please refer to HS program if available.)
Risk Factor 12
Defined as a child enrolled in ITCSP and eligible to transition into PA PKC.
Risk Factor 13
Providers wishing to prioritize specific geographic regions with higher rates of poverty may do so. This might include specific zip codes, school districts, or other factors.
Risk Factor 14
If a family concern is shared that is not covered by any of the other risk factors and the child has not yet been referred to EI for evaluation, the program should share information on EI.
Risk Factor 16
If a family concern is shared that is not covered by any other risk factors and the child has not yet been referred to EI for evaluation, the program should share information on EI.
Risk Factor 17
If a family concern is shared that is not covered by any other risk factors and the child has not yet been referred to EI for evaluation, the program should share information on EI.

By signing below, I acknowledge and agree to the following:

Acknowledgement #1(Required)
Acknowledgement #2(Required)
Acknowledgement #3(Required)
Acknowledgement #4(Required)
Acknowledgement #5(Required)
Acknowledgement #6(Required)
Parent/Guardian Certification To the best of my knowledge, the information provided in this application and the associated income documentation is accurate. I understand that I may be asked to verify or give proof of information provided. I certify that all information provided is accurate. I understand that eligibility is subject to verification and providing false information may result in disqualification.
Max. file size: 1 GB.
(Upload what applies: Pay stubs, previous year's W-2, Documentation for SSI, TANF, unemployment compensation, or Social Security benefits, Court orders for child support or foster care per diem letters). *Note: For foster children, a family size of one with zero income may be used.
Clear Signature
Parent/Legal Guardian Name