Enrollment Application

 
 
 Welcome! 

 
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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.


   
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  Thank you for submitting this application! 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

If you need assistance applying for CenClear's Early Childhood programs or have any questions please call 1-800-525-5437.
   
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  Thank You!
   
  Thank you for completing the application. A CenClear staff member will reach out to you about the service you are requesting.

Admission to CenClear programs is open to all regardless of race, color, national origin, sex, age, or disability.

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the agency (state or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877- 8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: How to File a Complaint. and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the in the form. To request a copy of the complaint form, call (866) 632-9992.

Submit your completed form or letter to USDA by: mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights, 1400 Independence Ave. SW Washington, D.C. 20250-9410, fax (202) 690-7442 or email program intake@usda.gov.

This is an equal opportunity provider.
CenClear is an equal opportunity employer and service provider that does not discriminate on any basis including a person’s age, sex, color, race, disability, religious creed, lifestyle or source of payment.

   
 
 
 
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