1Income Eligibility2Demographics3Primary Parent4Secondary Parent5Child Information Household Income Sources / Fuente del Ingreso Familiar(Required)EmploymentSelf-EmploymentUnemployment CompensationWorker's CompensationTANF Cash paymentsSocial SecuritySSIChild SupportAlimonyOtherWho contributes to the household income? / ¿Quien contribuye al ingreso familiar?(Required)Single ParentBoth ParentsOtherAnnual Household Income / Cuales son sus Ingresos al Año(Required)Family Size / Tamaño de la Familia(Required) Name, Ages and Relationship to child of all people living in the house / Favor de escribir nombre, edad y relacion con el niño de todas las personas que viven en su casa(Required)Proof of income: please upload the first page of your LAST Income Tax Return / Comprobante de Ingresos: Favor de adjuntar la primera pagina DE SU ULTIMO reporte de ImpuestosMax. file size: 8 MB.Please select if you didn't file a Income Tax Return 2023 / Seleccione, si usted no realizó declaracion de impuestos 2023 I did not file a 2023 Income Tax Return / No realicé los Impuestos de el año 2023 Employment Status of Primary Parent/Guardian / Cual es el estatus laboral del padre primarioSelect One / Seleccione unoEmployed Full Time / Empleado Tiempo CompletoEmployed Part Time / Empleado Tiempo ParcialUnemployed / DesempleadoOther / OtraIf you didn't have Income Tax return or if your income changed significantly, please upload a w2 or a recent paystub. If unemployed, please provide proof of any source of income. (ex: letter of child support, SSI award letter, CASH assistance, etc.)Max. file size: 8 MB.Employment Status of Secondary Parent/Guardian (If applicable) / Cual es el estatus laboral del padre Secundario (Si aplica)Select One / Seleccione unoEmployed Full Time / Empleado Tiempo CompletoEmployed Part Time / Empleado Tiempo ParcialUnemployed / DesempleadoOther / OtraIf you didn't have Income Tax return or if your income changed significantly, please upload a w2 or a recent paystub. If unemployed, please provide proof of any source of income. (ex: letter of child support, SSI award letter, CASH assistance, etc.)Max. file size: 8 MB.REQUIRED: Please check which eligibility factor applies to your child or family / Seleccionar que factor de eligibilidad aplica para su hijo(a) o familia:(Required) Child's Family or Living Structure: Single Parent. Child's Family or Living Structure: Divorced Parents. Child's Family or Living Structure: Relatives as Guardians. Teen Mother: A child whose mother was under the age of 18 when the child was born. Concerns regarding Child's Physical Development or Existing Medical Condition (Currently not receiving EI Services) Concerns regarding child's speech or Language Development (Currently not receiving EI Services) Concerns regarding Child's Social, Emotional or Behavioral Development. 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. 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. 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 due to one of the following: 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 lack of alternate accommodations; are living in emergency or transitional shelters; are abandoned in hospitals; or are awaiting foster care placement; 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; Children who are living in cars, parks, public places, abandoned buildings, substandard housing, bus or train stations, or similar settings. 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. Child lives in geographic area of high poverty. DemographicsEthnicity/Race(Required)Select One / Seleccione unoWhite.Hispanic or Latino.Black or African American.American Indian or Alaska Native.Asian.Native Hawaiian or Other Pacific Islander.Country of Origin(Required) What language do you speak at home?(Required) Primary ParentRelationship to Child/Parentezco con el niño(a):(Required)MotherFatherStepmotherStepfatherFostermotherFosterfatherGrandmotherGrandparentBrotherSisterUncleAuntOtherPrimary Contact Name and Last Name /Nombre y Apellido:(Required) First Last Cell-Phone / Telefono Celular(Required)Email/Correo Electronico(Required) Home Address (Street, Number, City, State, Postal Code)/ Dirección de casa (Calle, Numero, Ciudad, Estado, Codigo Postal):(Required) Street Address City State / Province / Region ZIP / Postal Code Employer Information / Informacion de Empleador Work Phone / Telefono de trabajoWork Address/ Direccion del Trabajo Secondary ParentRelationship to Child/Parentezco con el niño(a):(Required)MotherFatherStepmotherStepfatherFostermotherFosterfatherGrandmotherGrandparentBrotherSisterUncleAuntOtherPrimary Contact Name and Last Name /Nombre y Apellido:(Required) First Last Cell-Phone / Telefono Celular(Required)Email/Correo Electronico(Required) Home Address (Street, Number, City, State, Postal Code)/ Dirección de casa (Calle, Numero, Ciudad, Estado, Codigo Postal):(Required) Street Address City State / Province / Region ZIP / Postal Code Employer Information / Informacion de Empleador Work Phone / Telefono de trabajoWork Address/ Direccion del Trabajo Child InformationChild's First and Last Name(Required) First Last Gender(Required)FemaleMaleBirthday(Required) MM slash DD slash YYYY Age(Required)Allergies (Including Medication Reaction)/Alergias (Incluya medicamentos) Special Conditions or Dietary Restrictions/ Condiciones Especiales o Restricciones Alimenticias:
