Survey - Inquiry Pre-K Counts York Suburban

Inquiry Pre-K Counts York Suburban

Question - Required - Parent/Guardian Name

Question - Required - Child's Name

Question - Required - Email:

Question - Required - Child's Birth Date

Month

Day

Year

Question - Required - Home Address

Question - Required - City/State/ZIP

Question - Required - Phone Number

Question - Required - Is your family at or below the 300% poverty level? Must answer YES to qualify. (Persons in Household: 1-$38,280, 2-$51,720, 3-$65,160, 4-$78,600, 5-$92,040, 6-$105,480, 7-$118,920, 8-$132,360, Add $4,480 for each person over 8)

Question - Required - Has your child been referred to Pre-K Counts by a health/mental health practitioner?

Question - Required - Is the child in foster care, kinship care, or receiving Children and Youth Services? (You must be able to provide documentation.)

Question - Required - Guardian has NOT obtained a high school diploma or a GED?

Question - Required - Is English NOT the child's first language?

Question - Required - Is the child homeless?

Question - Required - Is one of the child's parents in prison?

Question - Required - Does the child have an active Individualized Education Plan (IEP)? (You must be able to provide the IEP.)

Question - Required - Is the child a migrant/seasonal student?

Question - Required - Was the child's mother under the age of 18 when the child was born?

Question - Required - Does the child have a sibling enrolled in a YWCA program? If so, which program?

Question - Required - Is your child currently enrolled in a YWCA program? If so, which program?

Question - Not Required - How did you hear about our program?

Question - Required - Which Pre-K Counts Program are you interested in?

Canadochy Elementary

Lincoln Charter School

Valley View Elementary

Question - Required - Please list your child(ren)'s school: