The Child Development and Family Council of Centre County

Philipsburg Pre-K Application

Pre-K Counts Application Form

Philipsburg Child Development Center

To apply for enrollment in the Pre-K program please complete the form below. If you have questions please call 814-342-5698.

Child's Information

First Name:
Middle Initial:
Last Name:
Date of Birth:

Child's Current Age
2 Years
3 Years
4 Years
5 Years

Child Care Needs
No Care Needed
Before Pre-K
After Pre-K
Before and After Pre-K

Family Information
Number of Family Members
Adults: Children:

Primary Language
English
Spanish
Other Please Specify:

Family Type
One Parent
Two Parent
Foster
Relative
Other Please Specify:

Household (Family) Size:

Parent or Guardian Information

First Name:
Last Name:
Address:
City:
Zip/Postal Code:
County:
Home Phone:
Work Phone:
Email:

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 - $60,000
$60,001 - $70,000
$70,001 - $100,000
More than $100,000

Child Eligibility Criteria (Check all that apply)

	Family income is at or below 300% of federal poverty level. Consider all sources of income.
	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: Guardian does not have a 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.
	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 the lack of alternative 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 spaces, abandoned buildings, substandard housing, bus or train stations, or similar settings.
	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 (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.

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

Philipsburg CDC �� Program Features� �� Hours� �� Location� �� Fees� �� Subsidized Care � �� Pre-K Counts � �� Enrollment

The Child Development and Family Council of Centre County

Philipsburg Child Development Center

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Pre-K Counts

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CCIS

Pre-K Counts Application Form

Philipsburg Child Development Center

To apply for enrollment in the Pre-K program please complete the form below. If you have questions please call 814-342-5698.