Community Services for Children | Additional Resources

CSC Child / Pregnant Mother

Application for Preschool Programs

Our Preschool Programs:

Early Head Start Services to pregnant women and infants through age 3
Head Start At Home Preschool in your home for children 2 years before kindergarten with health and family services
Head Start Preschool for children 1 and 2 years before kindergarten with health and family services
Pre K Counts Preschool for children 1 year before kindergarten

How to Apply for One of Our Programs:

Application Complete the attached application. If you need any help, please call us at 610-437-6000.
Date of Birth Provide a copy of your child's birth certificate or other document identifying your child's date of birth.
Income Provide documents to verify your household income for the past 12 months. This may include:
- Pay stubs or unemployment check
- W2 forms
- Tax Form 1040
- A written statement from an employer
- TANF statement
- If you are unable to send documentation of your income, please send a signed letter describing your circumstance.

Mail or Fax Application and above documents:
1520 Hanover Avenue, Allentown, PA 18109
Fax: 610-437-6500 ATTN: Enrollment Department

What Happens Next:

Review - Based on the information you give us and eligibility guidelines, we will let you know by mail if you are eligible.
Selection - Children are selected for the upcoming school year during the spring. We accept applications year"round. When we have an opening for your child, we will contact you to complete the enrollment process.
Priority - We prioritize children based on age, income, disabilities and other risk factors that show a high need for services.

Last Name First Name Middle Initial Date of Birth / Estimated Due Date

Age

Under 1
1
2
3
4
5
1 year before K
2 years before K

Gender Male Female

Primary Language

English
Spanish
Other Please specify:

How Well Does Child / Pregnant Mother Speak English Not At All Not Well Well Very Well

Family Type

One Parent
Two Parents
Foster
Relative / Grandparent
Other Please specify

Living Address Street Address City State Zip

Postal Address Street Address City State Zip

Daytime Caregiver Home Telephone Cell Phone Work Phone Email School District / Elementary School

Are you or have you been homeless in the past 12 months? Yes No

Housing Type

Apartment
Shelter
Temporary / Friend / Family
Mobile Home
Migrant Housing
Hotel / Motel
Other

Primary Language English Spanish Other Please specify

Best Way to Contact You? Phone Mail Email Best time to contact you?

Household Members

Please list all parents, guardians, and children up to age 18 living at the address listed above.

Household Member #1 Parent, Guardian or Child? Relationship Birthdate Race / Ethnicity Level of Education

Employment Status Full Time Part Time Unemployed Not Applicable

Add Member Remove Member

Do you have any concerns about your child's development? (check all that apply)

Physical Development
Vision
Speech
Hearing
Behavior
Health
Other Please describe your concerns

Does your child have a current IEP? Yes No

If yes, please indicate the Early Intervention/IU services your child is currently receiving:
(check all that apply) Speech Development Hearing Language Vision Occupationl/Physical Therapy Other Please specify

Are you or were you a teen parent? No Yes Age of first pregnancy

Are you currently pregnant? No Yes Estimated due date

If you are a pregnant mother, are you currently receiving prenatal care? No Yes If yes, where? When did your care begin?

Would you be able to provide daily transportation to a center (not all programs offer transportation)? No Yes How?

How did you hear about CSC's Early Childhood and Family Development Programs?