Pre-K Counts Scholarship Application

Filling out an application for a Pre-K Counts Scholarship is now easier than ever! You can fill out the application here on laptops, desktops or mobile devices.

"*" indicates required fields

Date Form is Completed*

Child's Name*

First

Middle

Last

Child's Age as of September 1, 2023*

Household (Family) Size*

Child's Birthday*

Primary Language*

Preferred Classroom Session

Family Type*

Is there a court order for custody?*

If there is a custody order, who has legal custody?

Certified court orders must be provided.

If applicable, upload the certified court order here.

Max. file size: 256 MB.

Name of parent completing the application*

First

Last

Email of the parent completing the application*

Address of the parent completing the application*

Street Address

Address Line 2

City

State

ZIP Code

County of the parent completing the application*

Cell Phone*

Work Phone

Home Phone

School district the child will attend*

Elementary school the child will attend*

Child's gender*

I certify that I am a legal resident of Pennsylvania*

Yes, I am a legal resident of Pennsylvania

Signature

If you are able to print this form, sign in this box.

Signature

Max. file size: 256 MB.

If you cannot print this form to sign it, you can take a picture of your signature with the words “Begin With Us Signature” in the picture and upload it here.

Household Yearly Income*

The person completing this application must attach copies of documents used to verify income with submission of application. Applications submitted without income will be considered incomplete.

Income includes:
Earned income: gross wages from work/cash-in-hand/self-employment.
Unearned income: alimony, child support, military family allotments, pensions, public assistance, Supplemental Security Income (SSI).
Unearned benefits: worker’s compensation, unemployment, lottery winnings, retirement benefits.

Income verification: pay stubs, W-2s, Internal Revenue Service tax forms, or written employer statement of anticipated earnings. Self-employment: tax returns, business records. Benefit check, bank statement, court order.

Income Verification Upload

Drop files here or

Max. file size: 256 MB.

Federal Poverty Guidelines

I have reviewed the federal poverty guidelines.

Please check all boxes that pertain to your family:

Family income is at or below 300% of federal poverty level. (Required risk factor for enrollment.)

Consider all sources of income as listed above. Income will be reviewed and verified prior to enrollment.

Other Child Eligibility Risk Factor Criterion (Must check all that apply. Verification is required for each risk factor identified.):

Behavioral or Health Support Services:

A child who was referred from an appropriately credentialed health or mental health practitioner who is not employed by the Pre-K Counts program; a child who is receiving mental health treatment.

Child Protective Services:

A child who is a foster child, a kinship care child, or receiving Children, Youth and Family services.

Education Level of Guardian:

Parent/Guardian does not have or is in the process of obtaining a high school diploma 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.

Teen Mother:

A child whose mother was under the age of 18 when the child was born.

Individualized Education Program (IEP):

A child who is currently enrolled in the preschool early intervention program with an active Individualized Educational Program (IEP). Verification would be a copy of the IEP or other source of documentation from the parent or early intervention provider.

Homeless:

A child who lacks a fixed, regular, and adequate nighttime residence due to one of the following: A- A child who is sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason; is living in motels, hotels, or camping grounds due to the lack of alternative accommodations; is living in emergency or transitional shelters; is abandoned in hospitals; or is awaiting foster care placement; B- A child who has 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- A child who is living in cars, parks, public spaces, 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 agricultural-related businesses such as meat or vegetable processing, working in nurseries such as Christmas and evergreen trees farming.

Incarcerated Parent:

A child, of which: one of the child’s parents is currently incarcerated.

If you marked "Incarcerated Parent" above, please enter the possible release from prison date:

Have you applied for any other sources of funding or to any other agencies for the 2022-2023 school year, including but not limited to: Pre-K Counts, Head Start, Early Learning Resource Center (formally known as Child Care Information Services (CCIS), scholarships, etc.?*

If you answered yes to the previous questions, please list all:

Do you anticipate needing child care before or after the school day?*

If you anticipate needing child care before and/or after, please specify:

How did you hear about our program?*

If you heard about us from a friend or relative, please specify who:

Please check this box to verify that you have completed this application with accurate information:*

To the best of my/our knowledge, the information provided is accurate. I/We understand that I/we will be asked to verify or substantiate the information provided.

This application will be considered incomplete if not submitted with proof of income and verification of any additional child risk factor criterion.

Please print parent/legal guardian's name:*

Date*

Signature

If you are able to print this form, sign in this box.

Signature

Max. file size: 256 MB.

If you cannot print this form to sign it, you can take a picture of your signature with the words “Begin With Us Signature” in the picture and upload it here.

Please print parent/legal guardian's name:

Date

Signature

If you are able to print this form, sign in this box.

Signature

Max. file size: 256 MB.

If you cannot print this form to sign it, you can take a picture of your signature with the words “Begin With Us Signature” in the picture and upload it here.

Congratulations, you are considering one of the most valuable experiences for your child that is available in early childhood education today. Begin With Us will provide your child with a strong foundation for learning with passionate teachers, hands on experiences, and developmentally appropriate curriculum. We encourage you to learn more about our program and your place as a parent in our learning community through our website: www.beginwithus.net

In order to better allow us to get to know your child, please complete the following four (4) questions:

Why would you like for your child to receive a scholarship?*

Please tell us about your child's strengths; and areas where a high quality early learning program would benefit your child.*

Why would begin with us be a good fit for your child?*

What do you think your child will like the most about attending begin with us?*

Office Use Only

Staff Verifying Income and Risk Factors Signature

Date

Staff Verifying Income and Risk Factors Signature

Date

Actual Annual Verified Gross Household (Family) Income:

Please include the date and signature of he parent or guardian to document that any family who is Head Start income eligible (100% of FPL or below) has been informed of their eligibility. The staff person that informs the parent/guardian must sign below.

If applicable, please ensure the parent/guardian signs and dates.

If applicable, the staff should sign and date above.

Head Start Eligible Families (100% of FPL or below)

Please include the date and signature of the parent or guardian to document that any family who is Head Start income eligible (100% of FPL or below) has been informed of their eligibility. The staff person that informs the parent/guardian must sign below.

I have been informed of my child’s eligibility for Head Start but may still choose to enroll in the Pre-K Counts program:

Parent/Legal Guardian Signature

Date

Parent/Legal Guardian Signature image

Max. file size: 256 MB.

If you cannot print this form to sign it, you can take a picture of your signature with the words “Begin With Us Signature” in the picture and upload it here.

Staff Signature

Date

Staff Signature image

Max. file size: 256 MB.

If you cannot print this form to sign it, you can take a picture of your signature with the words “Begin With Us Signature” in the picture and upload it here.

Headstart Applicability

Click on this radio button if not applicable for Head Start – N/A

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