Child's Name*
Child's Age as of September 1, 2023*
3 Years Old 4 Years Old 5 Years Old
Primary Language*
English Spanish
Preferred Classroom Session
8:30 a.m. – 3:00 p.m. 9:00 a.m. – 3:30 p.m. No Preference
Family Type*
One Parent Two Parents Foster Child Child Living With Relative
Is there a court order for custody?*
Yes No
If applicable, upload the certified court order here.
Name of parent completing the application*
Address of the parent completing the application*
School district the child will attend*
Altoona Area School District Bellwood Antis School District Hollidaysburg Area School District Spring Cove School District
Elementary school the child will attend*
Baker Elementary School Mowrie A Ebner Elementary School McAuliffe Heights Program at Irving School Juniata Elementary School Juniata Gap Elementary School Logan Elementary School The STEAM Learning Center at Penn-Lincoln Pleasant Valley Elementary School Myers Elementary School Charles W. Longer Elementary School Frankstown Elementary School Foot of Ten Elementary School Spring Cove Elementary School Martinsburg Elementary School
Child's gender*
Male Female
I certify that I am a legal resident of Pennsylvania*
Signature
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*
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 – $60,000 $60,001 – $70,000 $70,001 – $100,000 More than $100,000
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
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.)
Other Child Eligibility Risk Factor Criterion (Must check all that apply. Verification is required for each risk factor identified.):
Behavioral or Health Support Services:
Child Protective Services:
Education Level of Guardian:
English Language Learner:
Teen Mother:
Individualized Education Program (IEP):
Homeless:
Migrant: (Non-Immigrant)/Seasonal Student:
Incarcerated Parent:
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.?*
Yes No
Do you anticipate needing child care before or after the school day?*
Yes No
If you anticipate needing child care before and/or after, please specify:
Before Care After Care Both Neither
How did you hear about our program?*
Internet Search/Website Newspaper Advertisement Facebook Advertisement Recruiting Event Billboards Lives/Works Nearby (Location) Friend/Relative
Please check this box to verify that you have completed this application with accurate information:*
This application will be considered incomplete if not submitted with proof of income and verification of any additional child risk factor criterion.
Signature
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.
Signature
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
Parent/Legal Guardian Signature image
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 image
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