Early Childhood Education – Request Information

Thank you for your interest in the Community Action Partnership of Lancaster County’s Early Childhood Education Programs! Please fill out the form below and someone will be with you as soon as possible.

Click here to download the referral form (Eng) | Haga clic aquí para descargar el formulario de referencia (Esp)

Para español haga clic aquí

Thrive to Five - Request Information

Child's Name*
First Last
Child's Date of Birth*
MM slash DD slash YYYY
Language
Mother/Guardian's Name
First Last
Language
Relationship to the child (Mother, Foster Mother, Grandmother, etc.)
Father/Guardian’s Name
First Last
Relationship to the child: (Father, Foster Father, Grandfather, etc)
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
(home, cell, work)
Email*
Do you currently receive ELRC funds (formally CCIS)?*
- Yes
- No
Is there a custody agreement?*
- Yes
- No
Interested in applying for:*
- Infant/Toddler/Preschool Full Day
- Head Start
- PreK Counts
School District (if known)
Would you like translation services for your appointment?
- Yes
- No
File Upload
This is only for those who are applying for Head Start or PreK Counts funding programs. Please upload your files in the following formats (.jpg, .png, .pdf, .doc, .docx)
Child’s birth certificate or other proof of age verification
Max. file size: 128 MB.
Child’s immunization records
Max. file size: 128 MB.
Proof of income for 12 months (gross income)
Max. file size: 128 MB.
Questions & Comments

Early Childhood Education – Request Information

Thrive to Five - Request Information

File Upload