SUMMIT Early Learning, in partnership with several local school districts, is pleased to offer Pre-K Counts to families living in Snyder, Union, and Mifflin Counties. Pre-K Counts is a state-funded quality pre-kindergarten program operating for 180 days, with a focus on school readiness, and is free to families who qualify. Family earnings must be within 300% of federal poverty guidelines. (Click here for totals.)

PA PRE-K COUNTS APPLICATION

"*" indicates required fields

MM slash DD slash YYYY
Location*
Please check. (You must reside in the school district of listed location.)
Name (Child)*
MM slash DD slash YYYY
Parent/Guardian completing application*
Relationship to child (Select all that apply.)
Address
Primary Language
Family Type
Race (optional)
Ethnicity (optional)

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.
Other Household Members
Other Household Members
Other Household Members
Other Household Members
Other Household Members
Other Household Members
Household Income Sources (Select all that apply.)*
Employment Status of Parent/Guardian #2, if applicable
Select all that apply
Employment Status of Parent/Guardian #2, if applicable
Select all that apply
Other Child Eligibility Risk Factor Criterion (Please check all that apply.)

Prenatal/ Birth History

At what time during pregnancy with this child did you (or your child’s mother) first receive prenatal care:

Health History Information

Child's Health Insurance Provider:
Does your child have problems with eyes/sight?
Is your child wearing or supposed to wear glasses?
Does your child have any allergies?
Reactions:

Nutritional Information

Does your child eat anything that is not food?
Is your child currently receiving WIC services?
Does your family receive SNAP benefits?

Child Development

Is your child toilet trained?
Does your child need help going to the toilet?
Does your child use:
Does your child follow simple instructions?
Do you or others have any trouble understanding your child?

Concluding Questions

Are there any custody orders/concerns related to your child? (If yes, we will need a copy if enrolled.)
Consent*

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