Pre-K Counts Pre-Enrollment Year Round Enrollment for Child Advocates of Blair County Pre-K Counts Pre-K Counts Pre-Enrollment Application Childs Name Parent/Guardian Child's Birth Date Phone Cell Phone Parent/Guardian Email Address Best Time To Contact Address Who can we contact if we cannot reach you? Emergency Contact Name Emergency Contact Phone Family Information Number of people in your family Please check the range that best indicates last year's household income $0 - $10,000 $10,001 - $25,000 $25,001 - $40,000 $40,001 - $55,000 $55,001 - $70,000 $70,001 - $85,000 Over $85,000 Who does the child live with? Mother Father Both Mother & Father Grandparents Guardians Other Does anyone in your household receive a Supplemental Security Income (SSI) benefit? Yes No Special Needs/Disabilities Does your child have any special needs or disabilities? Yes No What types of disabilities? Speech Language Developmental Behavior Other Send
