Pre-K Counts Registration System

2024 Federal Poverty Levels
	Maximum income for eligibility in PreK Counts	Maximum income for eligibility in PreK Counts
Size of Household	300% weekly	300% annually
1	$868	$45,180
2	$1,179	$61,320
3	$1,489	$77,460
4	$1,800	$93,600
5	$2,110	$109,740
6	$2,420	$125,880
7	$2,731	$142,020
8	$3,041	$158,160
Additional family members	$310	$16,140

Enrollment Information:

Children must be 3 or 4 by September 1^st

Must meet financial eligibility (see chart below)

Parents provide transportation

Elligible Children may reside in Luzerne and Columbia Counties

Program Information:

Full day Session (8:40am-2:10pm) Monday thru Friday

Lead by PA Certified Teacher in Early Childhood Education & Highly qualified Full-time aide

1:10 Teacher/student ratio

Lunch & snacks provided

Steps for enrolling your child:

1.) Complete the application below.

2.) Contact Student Accounting at 570-542-4126 extension 5005 to make arrangements for supplying necessary documentation (see Pre-K Student Enrollment Checklist).

3.) When ALL documentation is submitted, your child’s name will be placed on the list. A point system is used to determine which students are accepted based on risk factors, age, etc.

You will be notified in June regarding acceptance to the program or if your child is on the waiting list.

Application

Child First Name *

Child Last Name *

Child Middle Name

Enrollment Year *

Student Race- Please check all that apply *

Student Ethnicity- Check all that apply *

Hispanic

Non- Hispanic

Unknown

Age *

Child Date of Birth * +

Child Gender *

Child last four digits of Social Security Number *

Please list any other languages besides English that are spoken in the home

Languages that the Child Speaks *

Is the Child receiving early intervention services? *

Yes

No

Special Needs/Concerns Related to Child

What is the local Elementary School for the Child?

What is the home school district for the Child? *

Guardianship

Parent/Guardian #1

First Name *

Last Name *

Gender *

Male

Female

Relationship to Child *

Father

Mother

Guardian

Other Other

Select *

Biological

Foster

Adoptive

Other Other

Role *

Primary Guardian

Secondary Guardian

Legal Guardian

Other Other

Date Of Birth * +

Email Address *

Primary Telephone Number *

Cell Phone Number

Physical Address *

Mailing Address (If different from Physical Address)

County of Residence *

Level Of Education *

Employment Status *

Employer Name

Employer Telephone

Employer Address

Parent/Guardian #2

First Name

Last Name

Gender *

Male

Female

Relationship to Child *

Father

Mother

Guardian

Other Other

Select *

Biological

Foster

Adoptive

Other Other

Role *

Primary Guardian

Secondary Guardian

Legal Guardian

Other Other

Date Of Birth +

Email Address

Primary Telephone Number

Cell Phone Number

Physical Address

Mailing Address (If different from Physical Address)

Level Of Education

Employment Status

Employer Name

Employer Telephone

Employer Address

Home/Income

Employment Status Guardian #1 *

Employed Full-Time

Employed Part-Time

Unemployed Unemployed

Employment Status Guardian #2

Employed Full-Time

Employed Part-Time

Unemployed Unemployed

Household income Sources (must check all that apply) *

Amount of income from all sources for all household members *

Attach documents used to verify income prior to enrollment *

Number of adults living in the household *

Number of children in the household *

In your current household: *

I rent my home

I own my home

I am living with another family

Other Child Eligibility Risk Factor Criterion (must 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 beyond the interview is required.

Child Protective Services: 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.

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

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.

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

Release of Information

When necessary to the fulfillment of the Pre-K Counts grant or to enhance services provided to my child or family, I authorize release and sharing of information to Luzerne County Intermediate Unit/Central Susquehanna Intermediate Unit (depending upon residency/local school district. *

Agree

Disagree

When necessary for the fulfillment or enhancement of the Pre-K Counts grant, I authorize the use of photographs in which my child appears for purposes including, but not limited to, newsletters, press releases, and/or brochures. *

Agree

Disagree

My Local School District is in The Pennsylvania Department of Education *

Yes

No

Additional Information

Are you currently enrolled in a Head Start Supplemental Assistance Program? *

Yes

No

Is your child enrolled in the Federal Head Start Program? *

Yes

No

Is your child enrolled in Child Care Works (subsidized child care)? *

Yes

No

Is your family part of the Child Welfare System? *

Yes

No

Does your child have behavioral supports or receive mental health treatment? *

Yes

No

Individualized Education Plan (IEP): Child who is currently enrolled in the early intervention program with an active IEP *

Yes

No

Is this child in foster care, kinship care, or receiving Child Protective service? *

Yes

No

English Language Learner: Child's First language is not English and is in the process of learning the English Langage *

Yes

No

Education Level of Guardian: Has high School Diploma, GED, or post secondary degree *

Yes

No

Is any one of the child’s parents incarcerated? *

Yes

No

Is the child homeless (living in a motel, shelter, in substandard housing… McKinley-Vinto Act for Guidance)? *

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

Was the child’s mother less than 18 years of age when he/she was born? *

Yes

No

To the best of my knowledge, the information provided is accurate. I understand that I may be asked to verify or substantiate information provided. *

Yes

No

Parent/ Guardian Full Name *

Date * +

Parent/Guardian Signature *

clear

Staff Full Name: Verifying Income and Risk Facors

Date +

Staff Signature: Verifying Income and Risk Facors

clear

FOR OFFICE USE ONLY

Income Verification

2021 Federal Poverty Level Guidelines

Family Size	100% (Head Start Eligible)	300% (Pre-K Counts Eligible)
1	$12,880	$38,640
2	$17,420	$52,260
3	$21,960	$65,880
4	$26,500	$79,500
5	$31,040	$93,120
6	$35,580	$106,740
7	$40,120	$120,360
8	$44,660	$133,980
Each Additional	+$4,540	+$13,620

Actual Annual Verified Gross Household (Family) Income:	$
*Attach copies of documents used to verify income prior to enrollment
Family Size (per PKC guidelines):

☐	Family income is at or below 300% of federal poverty level relative to family size (required risk factor). Consider all sources of income. Must be verified prior to enrollment.

Staff Verifying Income and Risk Factors Signature		Date

For Head Start Eligible families (100% of FPL or below)

I have been informed of my child’s eligibility for Head Start and given the following: ☐ Contact information for the following Head Start location _______________________________________ ☐ Application and/or assistance with referral ☐ Brochure or website with information about Head Start My signature below indicates that I have been informed about my options but may still choose to enroll in the Pre-K Counts program.

Parent/Guardian Signature		Date

Staff Signature		Date

Are you eligible for a Head Start Program? *