Emergency Contact Form

THE CHILD'S COMPLETE PRESCHOOL APPLICATION, FORMS AND ALL REQUIRED SUPPORTING DOCUMENTS MUST BE SUBMITTED AT THE TIME THE APPLICATION IS TURNED IN.

WE WILL NOT ACCEPT ANY APPLICATIONS WITHOUT ALL PAPERWORK. PLEASE SEE PAGE 2 FOR A CHECKLIST OF THE REQUIRED DOCUMENTS.

PARENTS MUST COMPLETE A FACE-TO-FACE INTERVIEW BEFORE AN APPLCATION CAN BE PROCESSED. TO SET UP AN INTERVIEW THROUGH ZOOM OR IN PERSON PLEASE CALL THE CENTER FOR Ms. Arlene Saunders at 215-224-6880.

SPACE IS LIMITED

UPDATED HEALTH ASSESSMENTS AND DENTAL FORMS WITHIN LAST 12 MONTHS MUST BE SUMMITTED WITH APPLICATION

...... Download the forms ......

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

# of People in household

# of People in family

Marital Status:

Married Single Widowed Separated/Divorced

Relationship to Child (Select one):

1. Parent/Step-Parent

2. Foster/Kinship Parent, related to child

3. Guardian, related to child

4. Other (specify):

5. Grandparent

6. Foster Parent, not related to child

7. Guardian, not related to child

8. Teen Parent - parent was under the age of 18 when child was born

Child is receiving Early Intervention services:

IEP

EFSP

Suspected

Child's mother and/or father is currently incarcerated:

Yes No

Housing Information — Select your current situation

1. Own

2. Shelter – Since what date?

3. Living with relatives or others due to lack of alternative, adequate housing or due to loss of housing

4. Temporary housing due to emergency: eviction, flood, fire, hurricane, etc.

5. Other

6. Rent

7. Transitional housing – Since what date?

8. Train or bus station, park or in car – Since what date?

9. Hotel/Motel, camping ground or similar – Since what date?

10. Abandoned apartment building

Optional Information

New to the country?

Yes No

Has an agency such as HIAS, NSC, Bethany, JEVS, New World Association, AFAHO, or other worked with you?

Yes No

Primary Caregiver Income			Secondary Caregiver Income
Employment Type	Amount	Frequency	Employment Type	Amount	Frequency
Employment			Employment
SSI/ TANF CASH			SSI/ TANF CASH
Unemployment			Unemployment
Other:			Other:

I understand that this information will be used to create my Parent Portal COPA account, and I will receive an email with my sign-in information at the email given on this form. I understand that my application is not complete until I sign in and upload all my supporting documentation.

Completing a Parent Portal COPA Account and submitting and finalizing an application does NOT guarantee that my child will be accepted to a preschool program.

Parent/Guardian Signature

Race/Ethnicity

Select all that applies

1. American Indian

2. Black or African American

3. Multi-Racial or Bi-Racial

4. Native Hawaiian

5. Pacific Islander

6. White

7. Other (specify):

Education

(Select highest Diploma/Degree earned or highest Grade Level completed)

1. High School Diploma

2. GED

3. ESL - English as a Second Language

4. Some college/Vocational/Associates

5. Bachelors/Advanced degree

6. Degree (th) Grade 11

7. 10th Grade

8. 9th Grade or lower

Employment, School, Job Training

Select all that apply

Employed/Self-Employed

Unemployed/Not Employed

Disabled

Member of the U.S. military on active duty

Veteran of the U.S. military

Do you have health insurance? provider:_________

If 'Yes', name of health insurance

Yes

Are you pregnant?

Yes

Are you receiving mental health treatment?

Yes

Do you receive benefits?

An adult who shares in the care of the child.

Employment, School, Job Training

Select all that applies

1. Employed/Self-Employed

2. Unemployed/Not Employed

3. Disabled

4. Veteran of the U.S. military

5. Member of the U.S. military on active duty.

Race/Ethnicity

Select all that applies

1. Hispanic or Latino/a

2. American Indian

3. Asian

4. Black or African American

5. Multi-Racial or Bi-Racial

6. Native Hawaiian

7. Pacific Islander

8. White

9. Other (specify):

I appreciate your interest in the Precious Angels Preparatory School preschool program! Completing and submitting a Preschool Application does not guarantee that your child will be accepted to a preschool program.

Required Documentation: Documentation of citizen status is NOT required. All families are welcome.

1. Applications will be processed when the documentation below is received

-> Completed application. Complete online

-> Proof of child's date of birth (Birth certificate, health insurance card, etc. Upload Document

-> Proof of TANF cash, SNAP/food stamps, other documentation of family income (W-2, etc.), or a signed statement of unemployment. Upload Document.

-> Proof of Philadelphia residency (bill, driver's license, lease, etc. Upload Document.

-> Child's health insurance car. Upload Document.

-> Picture identification of parent guardian (Current State or Federal Photo ID. Upload Document.

2. Enrollment will be finalized when the additional documentation below is received.

-> Child's health insurance card or proof of medical assistanc Upload Document.

-> The child's most up-to-date immunization record. Upload Document.

Child Health Form.

Upload Document.

Dental Exam Form.

Upload Document.

3. If applicable, additional documents may be needed:

-> Copy of child's IEP Upload Document.

-> Custody Order Upload Document.

-> Documentation of Medical Assistance: Upload Document.

-> Med-1 form if staff will need to administer medication to your child or use any medical equipment. Upload Document.

-> Copy of Foster. Upload Document.

-> Copy of McKinney Vento Letter: Upload Document.

EMERGENCY CONTACT / PARENTAL CONSENT FORM

PARENT’S NAME/LEGAL GUARDIAN

HOME TELEPHONE NUMBER

BUSINESS TELEPHONE NUMBER

PARENT’S NAME/LEGAL GUARDIAN

HOME TELEPHONE NUMBER

BUSINESS TELEPHONE NUMBER

EMERGENCY CONTACT PERSON(S) NAME

TELEPHONE NUMBER WHEN CHILD IS IN CARE

PERSON(S) TO WHOM CHILD MAY BE RELEASED

TELEPHONE NUMBER WHEN CHILD IS IN CARE

NAME OF CHILD’S PHYSICIAN/MEDICAL CARE PROVIDER

SPECIAL DISABILITIES (IF ANY)

ALLERGIES (INCLUDING MEDICATION REACTION)

MEDICAL or DIETARY INFORMATION NECESSARY IN AN EMERGENCY SITUATION

MEDICATION, SPECIAL SITUATION

ADDITIONAL INFORMATION ON SPECIAL NEEDS OF CHILD

HEALTH INSURANCE COVERAGE FOR CHILD or MEDICAL ASSISTANCE BENEFITS

POLICY NUMBER (REQUIRED)

EMERGENCY CONTACT / PARENTAL CONSENT FORM

PARENT’S SIGNATURE IS REQUIRED FOR EACH ITEM BELOW TO INDICATE PARENTAL CONSENT

OBTAINING EMERGENCY MEDICAL CARE

ADMIN. OF MINOR FIRST-AID PROCEDURES

PERIODIC REVIEW

IMPORTANT PRESCHOOL APPLICATION FOR ACADEMIC YEAR 2025-2026

THE CHILD'S COMPLETE PRESCHOOL APPLICATION, FORMS AND ALL REQUIRED SUPPORTING DOCUMENTS MUST BE SUBMITTED AT THE TIME THE APPLICATION IS TURNED IN.

WE WILL NOT ACCEPT ANY APPLICATIONS WITHOUT ALL PAPERWORK. PLEASE SEE PAGE 2 FOR A CHECKLIST OF THE REQUIRED DOCUMENTS.

PARENTS MUST COMPLETE A FACE-TO-FACE INTERVIEW BEFORE AN APPLCATION CAN BE PROCESSED. TO SET UP AN INTERVIEW THROUGH ZOOM OR IN PERSON PLEASE CALL THE CENTER FOR Ms. Arlene Saunders at 215-224-6880.

SPACE IS LIMITED

UPDATED HEALTH ASSESSMENTS AND DENTAL FORMS WITHIN LAST 12 MONTHS MUST BE SUMMITTED WITH APPLICATION

...... Download the forms ......

PRIMARY PARENT

HOUSING

Optional Information

FAMILY INCOME

Race/Ethnicity

Education

Employment, School, Job Training

Do you have health insurance? provider:_________

Are you pregnant?

Are you receiving mental health treatment?

Do you receive benefits?

SECONDARY PARENT

Employment, School, Job Training

PREK CHILD

Race/Ethnicity

I appreciate your interest in the Precious Angels Preparatory School preschool program! Completing and submitting a Preschool Application does not guarantee that your child will be accepted to a preschool program.

1. Applications will be processed when the documentation below is received

2. Enrollment will be finalized when the additional documentation below is received.

Child Health Form.

Dental Exam Form.

3. If applicable, additional documents may be needed:

EMERGENCY CONTACT / PARENTAL CONSENT FORM

PARENT’S SIGNATURE IS REQUIRED FOR EACH ITEM BELOW TO INDICATE PARENTAL CONSENT

OBTAINING EMERGENCY MEDICAL CARE

ADMIN. OF MINOR FIRST-AID PROCEDURES

PERIODIC REVIEW

Programs

Parent Newsletter

Emergency Contact Form

EMERGENCY CONTACT / PARENTAL CONSENT FORM

PARENT’S SIGNATURE IS REQUIRED FOR EACH ITEM BELOW TO INDICATE PARENTAL CONSENT

OBTAINING EMERGENCY MEDICAL CARE

ADMIN. OF MINOR FIRST-AID PROCEDURES

PERIODIC REVIEW

IMPORTANT PRESCHOOL APPLICATION FOR ACADEMIC YEAR 2025-2026

THE CHILD'S COMPLETE PRESCHOOL APPLICATION, FORMS AND ALL REQUIRED SUPPORTING DOCUMENTS MUST BE SUBMITTED AT THE TIME THE APPLICATION IS TURNED IN.

WE WILL NOT ACCEPT ANY APPLICATIONS WITHOUT ALL PAPERWORK. PLEASE SEE PAGE 2 FOR A CHECKLIST OF THE REQUIRED DOCUMENTS.

PARENTS MUST COMPLETE A FACE-TO-FACE INTERVIEW BEFORE AN APPLCATION CAN BE PROCESSED. TO SET UP AN INTERVIEW THROUGH ZOOM OR IN PERSON PLEASE CALL THE CENTER FOR Ms. Arlene Saunders at 215-224-6880.

SPACE IS LIMITED UPDATED HEALTH ASSESSMENTS AND DENTAL FORMS WITHIN LAST 12 MONTHS MUST BE SUMMITTED WITH APPLICATION

...... Download the forms ......

PRIMARY PARENT

HOUSING

Optional Information

FAMILY INCOME

Race/Ethnicity

Education

Employment, School, Job Training

Do you have health insurance? provider:_________

Are you pregnant?

Are you receiving mental health treatment?

Do you receive benefits?

SECONDARY PARENT

Employment, School, Job Training

PREK CHILD

Race/Ethnicity

I appreciate your interest in the Precious Angels Preparatory School preschool program! Completing and submitting a Preschool Application does not guarantee that your child will be accepted to a preschool program.

1. Applications will be processed when the documentation below is received

2. Enrollment will be finalized when the additional documentation below is received.

Child Health Form.

Dental Exam Form.

3. If applicable, additional documents may be needed:

EMERGENCY CONTACT / PARENTAL CONSENT FORM

PARENT’S SIGNATURE IS REQUIRED FOR EACH ITEM BELOW TO INDICATE PARENTAL CONSENT

OBTAINING EMERGENCY MEDICAL CARE

ADMIN. OF MINOR FIRST-AID PROCEDURES

PERIODIC REVIEW

Programs

Parent Newsletter

SPACE IS LIMITED

UPDATED HEALTH ASSESSMENTS AND DENTAL FORMS WITHIN LAST 12 MONTHS MUST BE SUMMITTED WITH APPLICATION