• Enrollment & Getting to Know You Meeting
  • Application for Admission of Child to School
  • Application for Pre-K Counts/Headstart Funding
  • Emergency Contact Form
  • Agreement Form
  • Residency Affidavit
  • Dental Assessment
  • Health Assessment (with date of exam)
  • Proof of Income
  • Photo ID of Primary caregiver
  • Insurance Card of Child
  • Birth Certificate
  • Received Shirt
  • Supply List
  • Parent Handbook
  • Permission for Photos
  • IEP letter
  • Child Pick-up Authorization
  • Emergency Operation Plan Letter
  • Transfer Letter
  • Transition Letter
  • Holiday Closing Schedule
  • C.B.S. State Food Program Application
  • Ages & Stages Questionnaires


55 PA CODE CHAPTERS 3270.124(a)(b), 3270.181 & 182, 3280.124(a)(b), 3280.181 & 182, 3290.124(a)(b), 3290.181 & 182



authorize Little Peoples Village to release my child(ren) to the person (s) designated. This is in consonance with Little Peoples Village Emergency Contact/Parental Consent Form.

Note: Parents and guardians should designate themselves and designated custodians.
Friends, neighbors and other relatives may also be designated.




Your child's growth and development is measured with developmental assessments. If your child currently has an IEP/IFSP, it would be beneficial to share a copy of this plan with us so we can work together to ensure that the guidelines are put into practice. You do not have to provide this information if you do not wish to do so.


Occasionally the Center staff or approved visitors take pictures of or videotape the children. You can be sure that we take precaution for our children and these pictures (still or moving) maybe used to publicize and promote Center activities or events. Pictures may appear in local newspapers, center brochures, or on television. No additional notice may be given of picture-taking sessions.


We also take the children out on trips to local parks or cites where there may be groups of people. For such occasions, at the time of registration, children are given a t-shirt that has our school logo and telephone number on it.


If you would like for your child's records to be transferred, we would need 72 hours’ notice. We would also need a written letter or form stating which records, why you want them to be transferred, and where you would like them to go.

My Child: No Yes Comments
Wears Diapers or Pull-ups
Wears Glasses or has a lazy eye, crossed eye, wandering eye or other eye condition
Has ear tubes, hearing loss, wears a hearing aid, has a history of ear infections or other ear conditions
Has excessive colds, sore throats, coughing episodes, snores loudly
Has a history of asthma or bronchitis
Has a heart murmur, a resolved heart murmur, rheumatic fever or other heart conditions
Has a history of anemia, sickle cell disease, elevated lead level
Has G6PD, hemophilia, or other blood conditions
Has an umbilical or inguinal hernia
Has reflux, stomach pain, diarrhea, constipation, trouble urinating, urinary tract infection or kidney disease
Has a feeding tube
Has diabetes (If yes, please indicate Type I or Type Il)
Has rashes, eczema, hives, boils
Has neuropathy, muscle tics, spina bifida, muscular dystrophy, cerebral palsy
Wears leg braces, uses a cane, walker, or wheelchair
Has/had polio, chicken pox, measles, mumps, scarlet fever, whooping cough
Experiences car sickness

Agreement Form

55 PA CODE CHAPTERS 3270.123&.18l(C); 3280.123&0l81 (c); 3290.123&.18I (c)

Type of Service:

Late fee's $10-5:31pm-5:36pm- $1.00 a min-After 5:36pm $25-PKC or Before care ONLY AFTER 3:01 pm

I, the parent/guardian;

  • Received complete written program information at the time of enrollment (S 3270.121, 3280.121, 3290.121)
  • Agree to update the emergency contact/parental consent for information whenever changes occur or every 6 months at a minimum. (S 3270.124, 3280.124, 3290.124)

Periodic Review


If "Getting to Know You" meeting was refused:

Questions that might be asked at enrollment.

Family Composition Questions
Child Information
Does your child do any of the following:
Does your child have any of the following allergies:
Describe your child's schedule:


Questions for the Parent


Handbook Acknowledgement

Agree to abide by the Center's Policies and Procedures

  • Have read this handbook in its entirety.
  • I agree to pick my child up on time.
  • I understand that tuition is due every Monday or Tuesday of each week.
  • I will keep my telephone and address information current at all times.
  • I will keep my child's immunization record up to date at all times.
  • Other  


FAMILY/CHILD VERSION: This should be initialed and signed by BOTH parents.

Please read and initial each statement below.

Symptoms include,

  • • Fever of 100.4 degrees Fahrenheit or higher
  • • Dry cough
  • • Shortness of Breath
  • • Chills
  • • Loss of taste or smell
  • • Sore Throat
  • • Muscle aches

While we understand that many of these symptoms can also be related to non-COVID-19 related issues we must proceed with an abundance of caution during this Public Health Emergency. These symptoms typically appear 2-7 days after being infected so please take them seriously. Your child will need to be symptom free without any medications for 72 hours before returning to the facility.

I, certify that I have read, understand, and agree to comply with the provisions listed herein.I acknowledge that failure to act in accordance with the provisions listed herein, or with any other policy or procedure outlined by Little Peoples Village will result in termination of services. I acknowledge that care for my child will be terminated if it is determined that my actions, or lack of action unnecessarily exposes another employee, child, or their family member to COVID-19.

Re-Opening LPV

Due to restrictions still in place, we will reopen at 75% capacity in each room. When instructed to and all safe measures are taken, we will open with full operation hours. It's impossible to have the same staff care for the same kids throughout the day without mixing up children and teachers from other classes so changes were made for everyone's safety.

New Temporary hours

We will be reopening Monday -Friday 7:30am-5:30pm. With only serving children no longer than 9 hours a day.

Same staff and same classroom

To help minimize interactions throughout the building, we are having all classrooms open throughout the day from open to close. This will help isolate any spread if a child or staff get sick. We will not be mixing the children or staff in different classrooms at any time. Same staff with same kids! Due to this guideline. We had to lower our hours to accomplish this goal. We will be open from 7:30-5:30pm and children can not exceed a 9hr period in a day. We also put a third teacher in each classroom to make sure all hours are covered, with same teachers, for the duration of the day.

Lower enrollment

We wil6 lower our enrollment to we feel it is safe per CDC guidelines to go to regular capacity. By limited capacity, we hope this will lower the chance of covid spreading.

Drop off/pick up and labeled Waiting Spots

Designated drop off/pick up for children will be in rear entrance yard. This will allow adequate space for social distancing. We will have markings 6 feet apart near entrances so families know where to stand safely from one another.

Only Students and Staff Allowed Inside

Each person who enters a facility increases the chances of COVID-19 transmission, so it is a good idea to keep families outside and not allow any visitors.

Designated Runner

Assign the same staff members the responsibility of greeting families and walking each child to their classroom.

Health Screening Questionnaire

Before a child is allowed inside, parents answer a questionnaire to ensure they do not have any signs of COVID-19. Here is a sample questionnaire you can use:

Do you or your child or any member of your household have any of the following symptoms? Fever (37.8C 100.4F Or Higher) New/Worsening Cough Shortness of Breath Sore Throat Difficulty Swallowing Loss of Taste or Smell Nausea/Vomiting, Diarrhea, Abdominal Pain Runny Nose, or Nasal Congestion (In the absence of underlying reasons such as Seasonal Allergies, Nasal Drip, Etc.) Unexplained Fatigue/Malaise/Myalgia Chills Headache Conjunctivitis (Pink Eye) Lethargy/Difficulty Feeding in Infants

Have you had contact with anyone with acute respiratory illness or who travelled outside of (country) in the last 14 days?

Have you had close contact with someone who has been diagnosed with COVID-19?

If you answered YES to any of these, DO NOT enter. Your child cannot be permitted to enter to ensure the safety of everyone. Contact your health care provider.

Temperature Checks

Check each staff and child's temperature using an infrared contactless forehead thermometer to ensure they do not have a fever before entering the building. This will be done at least twice a day to ensure temperature doesn't go up during the day.

Wear Masks

Ensure that every adult is wearing a face mask. Children under 3 years old should not wear face masks. There are mixed opinions on whether older children should wear masks and so unless legally required it is up to your discretion whether children should be required to wear them.

Contactless Check-in

Our staff member will check in/out children in for attendance on our childcare app daily.

Hygiene Station

Hand sanitizing station at the entrance of the building for all staff, parents and children to use before interacting with one another. Frequently washing hands with soap and water.

Indoor and Outdoor Play

Gross Motor activities are still included in your child's daily schedule but have been modified. Toddlers will only use the indoor play space which will be sanitized between each classroom use. Preschoolers and School Age children will use the outdoor play yard and equipment which will also be sanitized after each class use.

Scheduled Appointments

We will only take scheduled meetings with the directors, teachers and management. You must contact the front desk to schedule a meeting if necessary, to discuss any concerns. We want to ensure your safety as well as ours.

Outside Food (12 months and up) and Personal Items

Little Peoples Village has had a NO OUTSIDE FOOD Policy since September 2019, this will be strictly enforced as we reopen. NO food from outside is allowed in the center at this time. All personal items to include "inside shoes", additional clothing, blankets and crib sheets are to be brought upon return and LEFT at the center. We will wash and sanitize all personal items weekly. INFANTS: You still must bring pre-made bottles and baby food daily if applicable.

Greetings Parents,

The following program policies are designed to ensure that all enrolled children receive a quality preschool education.

Attendance Policy

Regular attendance is important for your child to maintain steady progress and to enjoy the benefits of a high-quality early childhood experience. If your child is ill or unable to attend school, please send your child's teacher a note to report the absence. Excessive absences are unacceptable and your child's enrollment in the program may be jeopardized. This policy also includes extended vacations.

  • First Occurrence (3 absences): Teacher will verbally remind parents about the importance of daily attendance.
  • Second Occurrence (5 absences): Teacher will meet with the parent/guardian to discuss the reason for absences and strategies to be utilized to avoid absences in the future.
  • Third Occurrence (10 absences): Program director will confer with the parent regarding excessive absences and develop a plan of action to ensure daily school attendance.
  • Fourth Occurrence (15 absences): Parent receives written notification that continued absences will result in child's removal from the class list.
  • Fifth Occurrence (18 absences): In consultation with the program director, the child is placed back on the waiting list and the slot will be filled by the next child on the waitlist.

Thank you for adhering o the program policies. Our goal is to support children and families whenever possible and it is never our wish for a child to be dismissed from our program. We hope that these policies and procedures will provide a foundation for a strong program that will meet the needs of students, parents, and staff.

Director, Little Peoples Village

I have received and understand Little Peoples Village Attendance Policy. I agree to contact my child's teacher when my child will be absent and/or in advance if there will be any prolonged absences from school. I further understand that I will provide documentation (doctor, dentist, family notes) when my child is absent from school. I understand that excessive absences may make it impossible for my child to remain in the PKC/Head Start program.

Document ID No. Title: Policy to Reduce and Ultimately Eliminate Suspension and Expulsion of Children Date Prepared:
Revision Effective Date:


This policy depicts LPVs methodology of reducing and eliminating the suspension and expulsion of children


The purpose of this policy is to identify positive behavior support guidelines and tools to be used by teaching and non-teaching staff at LPV; to raise awareness about suspension, expulsion and excessive disciplinary practices at the early childhood level to our families; to provide support through parent partnerships to help families who are experiencing challenging behaviors in the home by providing clear, age appropriate and consistent expectations and consequences to address challenging behaviors in a fair and equitable manner.


This procedure applies to all teaching and non-teaching staff; the guidelines are mandatory and must be practiced diligently prior to the advancement of the next tier level of addressing disciplinary action.


It is the responsibilities of the Executive Director, Director, Assistant Director to ensure teachers are empowered to implement all positive behavior tools as outlined in this policy and to provide teachers and support staff with adequate training and resources to address challenging behaviors in the classroom. At the completion of training, all staff and support staff will be responsible to ensure are implemented.


Teachers will implement the following strategies on a consistent basis to reduce challenging behaviors exhibited by children. Teachers will consistently document the use of these strategies and the results, whether positive or negative, daily.

Positive Behavior Support Strategies All Teaching and Non-Teaching Staff will implement the following procedures to curtail existing challenging behaviors exhibited by children in their care

Visual Supports

  • Design and post at children's eye level, a visual schedule complete with both pictures and words
  • The visual schedule is utilized consistently and adapted based on student needs


  • Design with children, and post 3-5 classroom rules with pictures
  • Classroom rules are positive, specific and descriptive
  • Classroom procedures, responsibilities, rules are explicitly taught and reviewed frequently

Praise and Positive Reinforcement

  • Behavior specific praise is used to reinforce appropriate behaviors
  • Praise is used when catching students make positive choices
  • Using a calm, low, neutral tone voice to provide short simple directions when redirecting inappropriate behaviors
  • A ratio of 4:1 (praise to behavior correction statements) is used
  • A combination of verbal and physical praise is used (e.g., thumbs up, high five, stickers, kiss your brain, tokens, etc.)

Transition Procedures

  • A warning of "one more minute" or something similar is used to signal a transition
  • A transition signal is used (ring bell, blow whistle, turn off lights, play a transitional song)
  • Provide personal face-to-face warning to children who have difficulty with transitions
  • Provide more than one reminder when possible (e.g., 5 minutes until... 2 minutes until...)
  • Expected behaviors are clearly stated at transition times (e.g., hands at side, quite mouths)

Provide Alternative Choices, if possible

  • Provide an alternative activity that will avoid disrupting others if child is unable or unwilling to participate in current activity
  • Permit child to sit in cozy corner to read; play with a puzzle, have writing center open and stocked with crayons, markers and paper to encourage writing or drawing; permit calming music to be played and/or any other calming activity
  • When child is redirected to the alternate activity, the child should be quietly praised and never punished

Allow Opportunities for helping

  • Develop and implement a job chart
  • Allow children to engage in jobs (e.g., wipe tables, organize toys, books, cubbies)

Introduce Scripted Stories

Implement scripted stories such as "Tucker the Turtle," and "Super Friend." Other suggested scripted stories can be located on the Center on the Social and Emotional Foundations for Early Learning (

  • Teach children how to identify their feelings (e.g., use visual feeling charts, games, puppets, etc.)

Practical Teacher Engagement with an aggressive or aggravated child

Teachers can sometimes help diminish and/or eliminate student's aggressive behaviors by implementing strategies listed above; as well as practicing the following step-by-step engagement procedures:

  • When a child exhibits aggressive behaviors that jeopardizes the physical safety of self, classmates and others, avoid physically handling or restraining the child. Only restrain a child if the child is a danger to himself and others
  • Never grab a child by the arms; if you need to remove a child from a dangerous situation, go behind him/her, and lift the child from under the armpits
  • Quickly relocate the child to a safe spot (writing center, cozy corner, etc.)
  • Give the child time to calm down; do not continue talking (badgering) the child during the calm down period. Let the child process and encourage child to take deep breaths.
  • During conversations with the child, keep your voice calm and in a low tone
  • Ask child what else can he/she do to calm down besides deep breathing. Listen and accommodate child with responses, if possible: count fingers, draw, exercise, etc.
  • Eliminate calling out a child's name repeatedly- It is bad press! It causes the child to be put on the spot; it encourages bad behavior and it gives other children a name to blame.
  • Once child has calmed down, revisit the discussion about what made the child upset and revisit alternative behaviors

If the above strategies fail to change inappropriate behaviors, advancement to the next level on the progressive disciplinary procedure will be implemented for the individual child.

  • Design specific strategies for individual children
  • Revisit the Tucker the Turtle Story daily and continue to have children practice the steps
  • Tailor the Tucker story to fit individual students (e.g., include child's name, specific behaviors exhibited by child, add child's picture, etc.)
  • Encourage and praise child for expressing his/her feelings
  • Remind him/her of strategies to regulate him/herself (e.g., counting down from 10, taking a walk, deep breathing, etc.)

If the use of these additional intervention strategies fails to improve challenging behaviors exhibited by children, advancement to the next level on the progressive disciplinary procedure will incur.

If the use of these additional intervention strategies fails to improve challenging behaviors exhibited by children, advancement to the next level on the progressive disciplinary procedure will incur.

Required Parent Conferences

  • Center director initiates a parent conference to discuss individual children's challenging behaviors
  • Director and parent collaborate to develop and implement an individualized plan to address learning goals and behaviors. Discussion will be held with child to demonstrate the partnership between the school and home. Director and parent will set a time-line and meet again to discuss child's progress
  • If behaviors continue, director will initiate another parent conference to revisit strategies implemented both at home and at school
  • If behaviors continue to persist, director initiates another parent conference to discuss agency intervention

Implement Agency Intervention

  • Director discusses with parents about agency intervention, if needed. Parents are provided contact information on our Mental Health Consultant and an appointment will be arranged.
  • Parent meets with the Mental Health Consultant and if agency intervention is required, parent provides permission for child to be screened
  • Director suggests parents take a dual-action approach in obtaining services; parent must contact outside services recommended by center as well as contact their individual insurance companies to get recommendations of other agencies to contact. Director provides recommended locations including:

Birth to 3 years of age:

  • Community Behavioral Health ( - 215-413-3100
  • City of Philadelphia Early Intervention Intake (Childlink) - 215-685-4646

3 to 5 years of age:

  • Child Crisis Treatment Center - 215-496-0707
  • Etwyn - 215-895-5500
  • Child Guidance Center- 267-713-4100
  • Community Council - 215-473-7033
  • Philadelphia Mental Health Clinic- 215-735-9379
  • NorthEast Treatment Center - 215-451-7000
  • Preschool Family Intervention Center through the Community Council - 215-473-7033
  • Director provides 15 days for parent to contact suggested providers and insurance company to schedule an appointment for child evaluation.
  • Call and Retrieve Procedure: During the 15-day period, the parent will be called if the child continues to injure him or herself; another child, a teacher or a staff person, and the student must be picked up within one hour. If the parent does not pick up the child within one hour, the child will not be able to return the next day.
  • If the parent refuses to seek additional help within the required timeline of 15 days, and if the child continues to injure him or herself; another child, a teacher or a staff person, the parent will be called to retrieve the child for the day. The parent will be given one hour to pick up the child. If the parent fails to pick up the child within one hour, the parent will have to keep the child home the following day.
  • If parent fails to pick up their child within one hour after two consecutive occasions, the parent will incur a late fee of $25.00 per hour until the child is picked up.
  • If the child continues to be incontrollable, and causes injury to him or herself, peers, teachers or staff persons; and/or child attempts to destroy center property, the parent will be called to retrieve the child, within one hour; and if behaviors persist for several days in a row, the parent will be required to keep the child home for a cool-down period of 1-3 days.
  • Parents must provide an appointment card to demonstrate good faith in scheduling the appointment.
  • The call and pick up procedure as described above will continue during scheduling of appointment and evaluation.
  • If parents fail to complete an evaluation within the second 15-day extension, the parent will be informed their child will be placed back on the waiting list for 30 days until an evaluation has been completed. As an alternative, the parent can provide their own wrap-around service for their child.
  • This extension will be the final opportunity for the parent to get child evaluated. During this holding period, parent is not responsible to make their copayments
  • Failure of the parent to complete an evaluation within the timeframe will result in the child being placed back on the waiting list until such services have been provided, and the childcare slot will be opened to other parents seeking childcare.
  • During the holding period, the call and retrieval of child for incidences of aggression that hurts child, teacher, peers or staff will continue until evaluation.
  • This extension will be the final opportunity for the parent to get child evaluated. During this holding period, parent is not responsible to make their copayments. Failure of the parent to complete an evaluation within the timeframe will result in the child being placed back on the waiting list until child have been evaluated and/or center support has been provided by the parent.

Extreme Circumstances:

  • If a child has demonstrated extreme aggression towards him or herself; teachers, staff and/or other children on a consistent basis, the above process will be eliminated, and the parent will be required to seek intervention on their own (resources provided in this policy) immediately prior to the child being able to return to the center. The parent must demonstrate good faith by submitting an intake appointment card with an upcoming date for the child to return and provide follow-up documentation indicating that the parent and child completed their intake services will be rendered to help support the child's aggressive behavior at the center and towards others. If the parent fails to keep the appointment, the child will be placed back on the waiting list until the services has been provided.
  • Any child that has been extremely aggressive and has broken any of the classrooms items, the parent will be responsible for replacement and/or purchase of the broken item.

Director's Name and Title

Director, Little Peoples Village II

I have received and understand Little Peoples Village Suspension and Expulsion Policy. I agree to adhere to the contents within.

Little People’s Village


The information and documentation you provide will assist the Office of Early Childhood Education in determining your eligibility for The School District of Philadelphia's preschool program, You are obligated to provide accurate and complete information. Deliberate misrepresentation of your information may subject you to prosecution under applicable Federal and/or State laws. PLEASE PRINT CLEARLY and use BLUE or BLACK INK.

Section 1: LOCATIONS

CHOOSE THE LOCATION(S) WHERE YOU WOULD LIKE YOUR CHILD TO ATTEND: Review the 2017-2018 School-Based Preschool Locations on pages 5-6. Select 1, 2 or 3 locations in preference order. If your child is accepted to preschool, the locations you select and the availability of funding in those locations will determine which location is chosen for your child, BEFORE-SCHOOL, AFTER-SCHOOL and TRANSPORTATION ARE NOT PROVIDED. You must be able to bring your child to school and pick up your child from school on time.

Section 2: CHILD

Race/Ethnicity Select all that applies

Mother Complete if child does not live with his/her mother

Father Complete if child does not live with his/her father

Little People’s Village


Section 2: CHILD. continued

Child's Doctor

Child's Dentist



The adult who is primarily responsible for the care and well-being of the child.

Employer Information Complete if you are Employed/Self-Employed

School/Job Training information Complete if you attend High School, College or a Job Training program


An adult who shares in the care of the child.

Employer Information Complete if you are Employed/Self-Employed

School/Job Training information Complete if you attend High School, College or a Job Training program


List your name, the name(s) of your child(ren) and the names of all other adults and children who live with you in your home. Use additional paper if needed
Self, Husband. Wife. Daughter. Son, Mother. Father Sister, Brother, Companion, Partner, Friend. etc.


Indicate how you financially provide for your family. Select each source of income that the Primary Parent, Secondary Parent and all children receive.


Read the following and sign where indicated.

l/We have completed all sections on my/our Child and Family Information Form and certify the information is correct. I/We understand that if any of my/our information is false, my/our participation in the preschool program may be terminated and l/we may be subject to legal action. l/We have attached a copy of my/our child's proof of date of birth, verification of my/our Philadelphia, PA address and copies of all income and monthly benefits that I/we and my/our children receive. l/We understand that this information is being given so that my/our eligibility can be determined for The School District of Philadelphia's preschool program. I/We understand that officials from The School District of Philadelphia, the Department of Health and Human Services and the Commonwealth of Pennsylvania will have access to and may verify the information and supporting documentation submitted with my/our Child and Family Information Form. l/We further understand that, if necessary, additional documents may be requested and I/we will comply with this request. l/We understand that my/our child's complete Preschool Application is confidential and will be held in strict confidence within The School District of Philadelphia and affiliated Community Nonprofit Partner Agencies that have been determined to be school officials under the Family Educational Rights and Privacy Act with legitimate educational interests as part of The School District of Philadelphia's preschool program.


Dear Parent/Guardian, The Child and Adult Care Food Program (CACFP) provides a daily nutritional breakfast, lunch and snack for your child at no cost to families. A monthly menu, posted in each location, lists the foods and beverages that your child is offered at each meal. The Office of Early Childhood Education recognizes the fact that certain foods, due to medical, religious or other reasons, are restricted from some children's diets. Please tell us about your child. This information will be shared with your child's nutritional, health and instructional staff. If your child has a non-disabling dietary restriction, efforts will be made to provide your child with an allowable substitution,

If your child has a food allergy or medical dietary concern that restricts his/her diet, the enclosed Medical Plan of Care Form for the Child ond Adult Care Food Program (Pages 33-34) must be completed by an appropriate health care professional and submitted with your child's Preschool Application. If your child has a food allergy which requires the administration of an EPI-PEN, Benadryl or other medication, please let us know immediately so that we can begin the process required to train the preschool staff.

Please check one box and complete as necessary — use additional paper if needed:

The information on this form is true to the best of my knowledge. I will inform my child's teacher if any of this information changes.

Early Childhood Use Only


Dear Parent/Guardian, The Office of Early Childhood Education recognizes the fact that some children have a medical condition that requires prescribed medication. When the prescribed medication is to be administered during preschool hours, a representative from Early Childhood Health Services, with written permission, will train the staff at your child's preschool to administer the medication to your child. Written permission is given by submitting form MED-1: Request for Administration of Medication, completed by you and your child's health care provider for each medication. At no time will medication be given to your child without a completed MED-1.

Please check one box and complete as necessary - use additional paper if needed:

The information on this form is true to the best of my knowledge. I understand that it is my responsibility to immediately inform my child's teacher or Early Childhood Health Services if there is a change to the information indicated above.

Early Childhood Use Only


Part I: Place a check mark in the No or Yes Column next to each item. For all Yes responses, please explain in the Comments column

Wear glasses
Have a lazy eye, crossed eyes, wandering eyes, other eye conditions
Have a history of ear infections, tubes in ears, hearing loss, wear hearing aid
Have excessive colds, sore throats, coughing episodes, or snores loudly
Have a history of asthma or bronchitis
Have a heart murmur, a resolved heart murmur, rheumatic fever or other heart conditions
Have a history of anemia, sickle cell disease, elevated lead level or other blood condition such as G6PD, hemophilia, etc.
Have or had an umbilical or inguinal hernia
Have a feeding tube
Have trouble urinating, urinary tract infection or kidney disease
Wear diapers/pull-ups
Have diabetes (If yes, please indicate Type I or Type II diabetes)
Have rashes, eczema, hives, boils
Have neuropathy, muscle tics, spina bifida, muscular dystrophy, cerebral palsy
Wear leg braces
Use a cane, walker or wheelchair
Have (or had) polio, chicken pox, measles, mumps, scarlet fever, whooping cough
Have car sickness
Have allergies due to medication or food
Have allergies due to seasonal changes, animals, or other
Take medication daily or on an “As Needed” basis

Little People’s Village


This form will be taken with your child when emergency medical care is needed.


Parents, you are responsible for making arrangements for alternate care for your child if s/he is ill, needs close supervision or has a contagious condition and cannot attend preschool. You are also responsible for transportation if your child has an illness or minor injury while at preschool, not sufficiently severe to warrant emergency medical transportation.

In the event your child becomes seriously ill or injured and requires immediate medical attention, s/he will be accompanied by staff and taken to the nearest hospital emergency room in an emergency medical vehicle. We will attempt to notify you at once. Under the Medical Services/Minor Act, immediate emergency treatment will be initiated at the hospital. However, it is essential that your child's teacher and the hospital is able to locate you as soon as possible, to give either written or monitored verbal permission for comprehensive treatment. Please be sure to keep your child's teacher informed about how to reach you at all times.

You are responsible for the costs of medical treatment if your child is injured. Please contact Early Childhood Health Services if your child needs medical insurance.

Doctor's note is required before your child can return to preschool if s/he has any of the following: an emergency room visit, certain cases of illness (contagious, serious, requires a long absence, surgery, etc.), or certain cases of injury (needing doctor's care, cast or brace. special activities, etc.). If you have any doubt, please obtain a doctor’s note whenever your child goes for medical care.

My signature below indicates that I understand the Emergency Medical Care Policies and give consent for:
  1. The administration of minor first aid to my child by preschool classroom staff.
  2. The emergency medical and/or dental care which may be necessary to preserve the life of my child or to prevent impairment of his/her health in the event that time does not permit obtaining my personal consent for such care I understand that I will be contacted as soon as possible, and will assume responsibility for giving permission for on-going care.
  3. My child to participate in the Office of Early Childhood Education's screening program which may include, but is not limited to: developmental screening, behavioral screening, vision screening, hearing screening and dental screening. I understand that as part of the preventative health program, children participating in preschool programs of The School District of Philadelphia receive screenings during the school year.

lf you have any questions about the above information, please speak with a representative from Early Childhood Health Services.

Early Childhood Use Only

Little People’s Village


Read the following statements and sign where indicated.

My/Our signature(s) below indicate that:
  1. The information I/we have provided on all of the forms in my/our child's Preschool Application is accurate and complete. I/we have signed all application forms where indicated and have included copies of all required supporting documents. If any of my/our information is false, my/our participation in the preschool program may be terminated and I/we may be subject to legal action.
  2. I/We understand that:
    1. The information contained in my/our child's Preschool Application will be held in strict confidence within The School District of Philadelphia and affiliated Community Nonprofit Partner Agencies that have been determined to be school officials under the Family Educational Rights and Privacy Act with legitimate educational interests as part of The School District of Philadelphia's preschool program.
    2. Completing and submitting a Preschool Application does not guarantee that my/our child will be accepted to a preschool program.
    3. Before my/our child's first day in preschool:
      1. I/We will attend an orientation meeting and an individual conference with my/our child's teacher and will receive a Parent Handbook.
      2. If my/our child's physical and/or dental exam dates are more than twelve (12) months old, I/We will be required to submit an up-to-date Child Health Assessment/Physical Exam Form, including a current immunization record and/or Child Dental Health/Dental Exam Form.
      3. I/We may be required to re-verify my/our Philadelphia, PA address, family income and/or monthly benefits.
      4. I/We will be notified if additional forms and/or documents are needed and will submit them as necessary.
  3. During the time my/our child is enrolled in preschool:
    1. S/He will attend every school day, his/her health permitting.
    2. S/He will be escorted to and from school by an individual who is at least eighteen (18) years old.
    3. S/He will be able to use the toilet with minimal adult assistance
    4. I/We will abide by all program policies stated in the Parent Handbook and will adhere to the scheduled arrival and departure times for his/her location.
    5. I/We will keep my/our child's information current and inform his/her teacher and the Office of Early Childhood Education of any changes.
    6. I/We will always make sure my/our child's teacher has an active telephone number from within the Philadelphia calling area for me/us so that I/we can be contacted should the need arise.

2022-2023 PA Pre-K Counts Enrollment Form

(This information is confidential to the PA Pre-K Counts program)
List Household Members below for determination of family size (required):
Relationship to Child Age
Per PKC Statute, Regulations, and Guidance, the following members of the household are included in family size:
  • Parent of the child (biological or adoptive mother or father, stepmother or stepfather, caretaker or spouse)
  • A biological, adoptive, unrelated or foster child or stepchild of the parent or caretaker who is under 18 years of age and not emancipated.
  • A child who is 18 years of age or older but under 22 years of age who is enrolled in high school, a general educational development program, or a post-secondary program leading to a degree, diploma or certificate and who is wholly or partially dependent on the income of the parent or caretaker or spouse of the parent or caretaker.
  • Others supported by the income of the parent(s) or guardian(s) of the child enrolling or participating in the program. If counted toward family size, any applicable income of these persons must also be counted for eligibility purposes.
Note: A family size value of one (1) with an income of $0 is entered when a foster child is applying for Pennsylvania Pre-K Counts.

Other Child Eligibility Risk Factor Criterion (Must check all that apply):

Behavioral Supports: A child who was referred to PA Pre-K Counts from an appropriately credentialed health or mental health practitioner who is not employed by the PA Pre-K Counts program; a child who is receiving mental health treatment. Additional verification beyond the interview is required.
Child Protective Services: A child who is a foster child, a kinship care child or receiving Children and Youth services.
Education Level of Guardian: Does not have high school diploma or GED or post-secondary degree.
English Language Learner: A child whose first language is not English and who is in the process of learning English is considered an English Language Learner.
Individualized Education Plan (IEP): A child who is currently enrolled in the Preschool Early Intervention program with an active IEP. Verification would be a copy of the IEP or other source of documentation from the parent or Early Intervention provider.
Incarcerated Parent: A child for whom one of the child’s parents is currently in prison.
Homeless: A child who lacks a fixed, regular, and adequate nighttime residence due to one of the following:
  1. Children who are sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason; are living in motels, hotels, or camping grounds due to lack of alternate accommodations; are living in emergency or transitional shelters; are abandoned in hospitals; or are awaiting foster care placement;
  2. Children who have a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings;
  3. Children who are living in cars, parks, public places, abandoned buildings, substandard housing, bus or train stations, or similar settings.
Migrant (Non-Immigrant)/Seasonal Student: A migrant child has moved from one school district to another in order to accompany or to join a migrant parent or guardian, who is a migratory worker or migratory fisher, within the preceding 36 months, in order to obtain temporary or seasonal employment in qualifying agricultural or fishing work including agri-related businesses such as meat or vegetable processing, working in nurseries such as Christmas and evergreen trees farming.
Teen Mother: A child whose mother was under the age of 18 when the child was born.

To the best of my knowledge, the information provided in this application and the associated income documentation is accurate. I understand that I may be asked to verify or substantiate information provided.

Completed by your child's dentist return this form with your child's application




Pennsylvania law requires that students attending school in the Commonwealth receive periodic dental examinations at stated intervals (upon original entry, while in third grade, and while In seventh grade).

These examinations are required for school attendance. Payment for these examinations is the responsibility of the parent/guardian. If the student/family does not have health insurance the school nurse will help the family apply for health insurance. Please attach a copy of the student's dental examination or record the data below.

Thank you for your cooperation.