YMCA of Greater Erie

Child's Name*

First Last

Parent's Name*

First Last

Relationship to Child*

Father
Mother
Guardian

(Select)

Biological
Foster
Adoptive

Role

Primary Guardian
Secondary Guardian
Legal Guardian

Address*

Street Address City State ZIP Code

Phone*

Email*

Child's Birthdate*

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Child's Gender

Male
Female

Child's Gender*

School District of Residency*

Child's Primary Language*

Is your child currently enrolled in a YMCA Program?*

Yes
No

Are you currently enrolled in the Infant Toddler Contracted Slots Program?*

Yes
No

The PKC program is a free program that runs 2.5-5 hours depending on location. If you need care outside those hours, you may receive wrap care at a cost. Will you be needing wrap care for your child?

Yes
No

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(Disabled) Please choose the method of instruction you are applying for

If the site chosen is full and you wish to participate virtually until a spot is available, please choose both options.

On-site
At-home learning

At-home Learning*

Do you have access to the technology required to use the Teaching Strategies app for communication in the event of a school closure?

Yes
No

Classroom Site Requested*

Family Type*

(If a 2 parent household, income must be included for both parents)

List Household Members below for determination of family size:*

Relationship to Child	Age

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.

Employment Status of 2nd parent/guardian (if you chose two parent family you must indicate the employment status of the second caregiver):*

Employment Status of parent/guardian:*

Employed Full-Time
Employed Part-Time
Unemployed

Household Income*

(Required qualifying factor) Must be below 300% on income guideline chart to qualify: Please check box for your household income:

Household Income Sources*

Must check all that apply. You are required to submit documentation for all income sources checked. Documentation will be collected in a follow up email.

Other Household Income Source:

Additional Qualifying Factors

(Check all that apply)

Acknowledgment and Sign Off

Acceptance is not guaranteed*

I understand that completion of this application does not guarantee my acceptance into the Pre-K Counts program.

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In the event that I am not chosen for the Pre-K Counts program at the location I specified; I give my permission to share my information with other Pre-K Counts/Head Start programs in the vicinity of the program requested:

Yes
No

If your income is 100% of FPL or below, you are Head Start Eligible. You can find information on the program, including enrollment information at cdcenters.org or by calling (814) 670-0643.

For application and/or assistance with referral, contact [email protected].

Persons in family/household	Poverty guideline
1	$15,060
2	$20,440
3	$25,820
4	$31,200
5	$36,580
6	$41,960
7	$47,340
8	$52,720
Each Additional	+$5,140

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.

Accurate Information*

To the best of my knowledge, the information provided is accurate. I understand that I may be asked to verify or substantiate information provided. I am giving permission for the PA Pre-K Counts program to provide this information to the Pennsylvania Department of Education to meet required reporting for the program.

Medical records

I understand I am required to provide a complete up to date physical and immunization records, as well is vision, hearing, and dental screening results my child may have had. If vision, dental, and hearing screenings have not been performed, I consent to onsite screening through the Pre-K Counts program.

Parent Name*

First Last

Consent*

I acknowledge I have received and reviewed the following:

Pre-K Counts Attendance Policy and Remote Learning Agreement

Parent Signature*

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Date