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*
MM slash DD slash YYYY
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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
Household Income Documentation*
Please check box for type you will provided. (Documentation will be collected in a follow up email):
- 2021 Income Tax Forms
- 2021 W-2's
- Current Pay Check Stubs (6)
- Social Security for all household members
- DHS Documentation
- CCIS Income verification form
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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*
- Downtown
- Eastside
- Early Learning Center
- Early Learning University
- Glenwood
- McKean
- Northwestern
- Summit
- Wattsburg
- Waterford
Family Type*
(If a 2 parent household, income must be included for both parents)
- Single Parent
- Two Parent
- Foster
- Child Living with Relative
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 applicable):
- Employed Full-Time
- Employed Part-Time
- Unemployed
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:
- Less than $5,000
- $5,001 - $10,000
- $10,001 - $15,000
- $15,001 - $20,000
- $20,001 - $25,000
- $25,001 - $30,000
- $30,001 - $35,000
- $35,001 - $40,000
- $40,001 - $45,000
- $45,001 - $50,000
- $50,001 - $55,000
- $55,001 - $65,000
- $65,001 - $70,000
- $70,001 - $75,000
- $75,001 - $80,000
- $80,001 - $85,000
- $85,001 - $90,000
- $90,001 - $95,000
- $95,001 - $100,000
- More than $100,000
Household Income Sources*
(Must check all that apply):
- Employment
- Self-Employment
- Unemployment Compensation
- Worker’s Compensation
- TANF Cash payments
- Social Security
- SSI
- Child Support
- Alimony
- Other
Additional Qualifying Factors
(Check all that apply)
- Education level of guardian: does not have a high school diploma or GED or post-secondary degree
- Behavioral Supports: A child who was referred to PA Pre-K Counts from an appropriately credentialed health or mental health practitioner; 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
- English Language Learner: A child whose first language is not English and who is in the process of learning English.
- Incarcerated Parent: A child for whom one of the child’s parents is currently in prison
- 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
- Migrant (nonimmigrant)/ 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.
- Teen mother: A child whose mother was under the age of 18 when the child was born
- Homeless: A child who lacks a fixed, regular, and adequate nighttime residence due to one of the following: A. 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 the lack of alternative accommodations; are living in emergency or transitional shelters; are abandoned in hospitals; or are awaiting foster care placement; B. 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; C. Children who are living in cars, parks, public spaces, abandoned buildings, substandard housing, bus or train stations, or similar settings
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	$14,580
2	$19,720
3	$24,860
4	$30,000
5	$35,140
6	$40,280
7	$45,420
8	$50,560
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
MM slash DD slash YYYY

Relationship to Child	Age

Pre-K Counts

Acknowledgment and Sign Off