Pre-K Counts Registration System

Enrollment Information:

Children must be 3 or 4 by September 1st

Must meet financial eligibility (see chart below)

Parents provide transportation

Children may reside in Northwest, Benton, Lake-Lehman and Nanticoke School Districts

 

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

 

 

2021 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

$743

$38,640

2

$1,005

$52,260

3

$1,267

$65,880

4

$1,529

$79,500

5

$1,791

$93,120

6

$2,053

$106,740

7

$2,315

$120,360

8

$2,577

$133,980

Additional members

$262

$13,620

 

 

 

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
Student Ethnicity- Please check all that apply *
 +
Is the Child receiving early intervention services? *
Guardianship
Parent/Guardian #1
Gender *
Relationship to Child *
 
Select *
 
Role *
 
 +
Parent/Guardian #2
Gender *
Relationship to Child *
 
Select *
 
Role *
 
 +
Home/Income
Employment Status Guardian #1 *
 
Employment Status Guardian #2
 
Household income Sources (must check all that apply) *
 

In your current household: *
Other Child Eligibility Risk Factor Criterion (must check all that apply)
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. *
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. *
My Local School District is in The Pennsylvania Department of Education *
Additional Information
Are you currently enrolled in a Head Start Supplemental Assistance Program? *
Is your child enrolled in the Federal Head Start Program? *
Is your child enrolled in Child Care Works (subsidized child care)? *
Is your family part of the Child Welfare System? *
Does your child have behavioral supports or receive mental health treatment? *
Individualized Education Plan (IEP): Child who is currently enrolled in the early intervention program with an active IEP *
Is this child in foster care, kinship care, or receiving Child Protective service? *
English Language Learner: Child's First language is not English and is in the process of learning the English Langage *
Education Level of Guardian: Has high School Diploma, GED, or post secondary degree *
Is any one of the child’s parents incarcerated? *
Is the child homeless (living in a motel, shelter, in substandard housing… McKinley-Vinto Act for Guidance)? *
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. *
Was the child’s mother less than 18 years of age when he/she was born? *
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 *
clear
 +
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)                               ☐   Check if not applicable          

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

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