Enrollment Application

Welcome to
CenClear's Enrollment

 
We are so pleased you are considering CenClear for your child!

All of the information in this document will be treated confidentially by CenClear staff. This form is being completed on a secure site.

Applying to CenClear's programs does not guarantee acceptance. CenClear's Head Start and PA PreK Counts programs are state and federally funded and do have income eligibility requirements. Prior to the child being accepted into the program, the family income must be verified by CenClear staff. Once the application is submitted, you will be contacted by a CenClear staff member to let you know if your child may qualify for the program, to discuss the next step, and to answer any questions you may have.

Application Form
Please check the services you are applying for*:
Services for children birth through 3-years-old
Services for children 3 to 5-years-old
Services for Pregnant Mothers
Services for Pregnant Teens
Other
Please specify:
Child Information*
Child's First Name*:
Middle Name:
Last Name*:
Child's Sex*:
Does the child have a disability*:
If yes please specify or include any concerns:
Is this child a foster child*:
Applicant's Information*
Birth Date:
Mailing Address:
City:
State:
Zip Code:
County:
Parent/Guardian Information*
First Parent/Guardian First Name*:
First Parent/Guardian Last Name*:
First Parent/Guardian Relationship to Child*:
First Parent/Guardian Phone (Home/Message; Please uses dashes ex. 814-342-5678)*:
First Parent/Guardian Email*:
First Parent/Guardian Education Level*:
Second Parent/Guardian First Name*:
Second Parent/Guardian Last Name*:
Second Parent/Guardian Relationship to Child*:
Second Parent/Guardian Phone (Home/Message; Please use dashes ex. 814-342-5678)*:
Second Parent/Guardian Email*:
Second Parent/Guardian Education Level*:
What school district does the child primarily live in:
Child lives with*:
Both Parents/Guardians
Father
Mother
Other
Please specify:
Do you have other children currently enrolled in CenClear preschool programs? If "yes" please list their first, middle and last name here:
Family Income:
Your Access Number if Applicable:
Number of people supported by above income*:
Please provide directions to your home and the physical address if different from the mailing address. If your home sits back off the road please explain how to get there. Example Turn onto the alley by the third house (blue) on Main Street. My house has green shutters and is about 1/2 a mile down the alley on the left *:
Please tell us the name of the preschool teacher or home visitor that referred you to CenClear. If you were referred by a parent please include their full name and address.* If you were not referred to CenClear by anyone please type "N/A":
I understand this information will be used to enroll my child in CenClear programs if the child qualifies. I understand CenClear will follow priority codes when enrolling children. I certify the information I provided is accurate. * I understand my typed signature carries the same weight as my written signature.:
Where did you hear about CenClear*:
If you were referred by another parent/guardian of a student that attended CenClear, please include the name of the person who referred you and their address:
For referral use Only. Please enter your email address:

Thank you for
submitting this application!

If you need assistance applying for CenClear's Early Childhood programs or have any questions please call 1-800-525-5437.

Next, you will be contacted by a CenClear staff member to let you know if your child may be eligible for a CenClear program.

If it is determined your child is eligible for a CenClear program, financial information will have to be submitted. All of the following information that applies to you will need to be submitted:

  • Income information from your 1040-A tax form
  • W-2 forms
  • Pay Stub
  • Social Security information for you and your child
  • Your Access Number
  • Earned Income Number Amount
  • Veteran's Benefits Amount
  • Social Security Benefits Amount
  • Unemployment Compensation Amount
  • Public/Cash Assistance Amount
  • Supplemental Income Amount
  • Alimony Amount
  • Child Support Amount
  • Workmen's Compensation Amount
  • Financial Assistance or Education Amount
  • Income received on behalf of a foster child
  • Any other information needed to determine your gross income