Keystone STARS Enrollment Application

Welcome to Keystone STARS - Keystone STARS is the PA Department of Public Welfare, Office of Child Development's voluntary continuous quality improvement program for early care and education. The program is operated through the Pennsylvania Early Learning Keys to Quality system, which encourages and supports early learning programs and practitioners in improving outcomes for children.

While working through the STARS program, providers are assisted by a Keystone STARS Representative (called a Specialist in the Southeast Region) at the Regional Key and other STARS service partners to secure resources, professional development opportunities, and financial supports needed to improve quality. For more information on Keystone STARS and the Pennsylvania Early Learning Keys to Quality system, please access our web site at www.pakeys.org.

The purpose of this application is to enroll in the Keystone STARS quality improvement program. Please complete the Enrollment Application below and send copy of your current DPW Certificate of Compliance or Registration to the Regional Key. A Keystone STARS Representative will be assigned to the facility upon receipt of a completed application.

Once enrolled, you will receive a phone call from your STARS Representative. They will help guide you through the next steps of participation in Keystone STARS, answer your questions and provide resources to help you along the way. If you have questions at any time during your enrollment in Keystone STARS, please contact SERK.

* = required field

Name of Facility (As it appears on DPW Certificate of Compliance/Registration): *

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Address (As it appears on DPW Certificate of Compliance/Registration): *

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City/State: *

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Zip Code: *

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County: *

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Check "yes" if the Regional Key should use the above as the Correspondence Address for this facility:

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Phone Number (where you care for the children): *

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Ext:

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Fax:

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Contact Person: *

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Title:

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Email: *

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Facility type (Check one): *

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Is this a School Age Only site? *

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Certificate of Compliance # (Center/Groups Only):

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Expiration Date:

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SSN or FEIN (Family Only):

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Legal Entity Name:

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Address:

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City/State:

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Zip Code:

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Contact Person:

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Check "yes" if the Regional Key should use the above as the Correspondence Address for this facility:

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Phone Number:

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Ext:

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Fax:

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Email:

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Facility Enrollment Breakdown: Complete the following table indicating your enrollment for any one day during the month of April or October, whichever is most recent.

How many children in the following age groups are enrolled in - Your child care? Head Start (only)? Early Intervention (only)? TOTAL
Infant/Toddler


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Preschool


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School-Age


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TOTAL


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I attest that all classrooms where child care children are enrolled meet DPW compliance at all times, regardless of affiliation with other organizations, such as PA Department of Education and Head Start. *

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Electronic Signature of the Individual Who is Legally Authorized to Represent the Facility: *

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Title: *

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Date: *

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