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 click the services you are applying for*:
Child or pregnant mother's Information (For applicant only)*
First Name*:
Middle Name:
Last Name*:
Child's Sex*:
Does the child or pregnant mother have a disability*:
Is this child or pregnant mother a foster child?*:
Applicant's Information*
Child or pregnant mother's Birth Date*:
Mailing Address*:
City*:
State*:
Zip Code*:
County*:
What school district does the child primarily live in:
Child lives with*:
If other, please specify:
1st Parent / Guardian (required)
Parent/Guardian First Name*:
Parent/Guardian Last Name*:
Parent/Guardian Relationship to Child*:
Parent/Guardian Phone Number*:
Parent/Guardian Email Address*:
2nd Parent / Guardian (optional)
Parent/Guardian First Name:
Parent/Guardian Last Name:
Parent/Guardian Relationship to Child:
Parent/Guardian Phone Number:
Parent/Guardian Email Address:
How did you hear about CenClear*:
If other, please specify:
Please tell us the name of the preschool teacher, home visitor, family service worker, or other CenClear staff that referred you to our Early Childhood program. If you were referred by a parent, please include their full name and address.:
I understand this information will be used to enroll myself/my child in a CenClear Early Childhood program if the child/pregnant mother qualifies. I understand CenClear will follow eligibility requirements and will prioritize using eligibility criteria points when enrolling children. I certify the information I provided is accurate. * I understand my typed signature carries the same weight as my written signature.*:

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