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 either a Manager or Specialist) 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 attached Enrollment Application that is appropriate to the type of program
operated (DPW certified/regulated or NON DPW certified/regulated) and return it 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 your Regional Key at the following:
Northeast Regional Key
1520 Hanover Avenue
Allentown, PA 18109
(800) 528- 7222
Counties Served – Berks, Bradford, Bucks,
Carbon, Columbia, Lackawanna, Lehigh, Luzerne,
Lycoming, Monroe, Northampton, Pike, Schuylkill,
Sullivan, Susquehanna, Tioga, Wayne, Wyoming
Northwest Regional Key
3823 West 12th Street
Erie, PA 16505
(800) 860-2281
South Central Regional Key
13 West Market Street
York, PA 17401
(800) 864-4925
Counties Served – Armstrong, Beaver, Blair,
Butler, Cambria, Cameron, Centre, Clarion,
Clearfield, Clinton, Crawford, Elk, Erie, Forest,
Indiana, Jefferson, Lawrence, McKean, Mercer,
Potter, Venango, Warren
Counties Served – Adams, Chester, Cumberland,
Dauphin, Franklin, Fulton, Huntingdon, Juniata,
Lancaster, Lebanon, Mifflin, Montour,
Northumberland, Perry, Snyder, Union, York
Southeast Regional Key
260 S. Broad Street, 18th Floor
Philadelphia, PA 19102
(267) 773-4400
Southwest Regional Key
305 Wood Street
Pittsburgh, PA 15222
(877) 349-4850
Counties Served – Delaware, Montgomery,
Philadelphia
Counties Served – Allegheny, Bedford, Fayette,
Greene, Somerset, Washington, Westmoreland
KEYSTONE STARS ENROLLMENT APPLICATION
DPW CERTIFIED OR REGULATED FACILITIES
Instructions: Please complete this form and return to the Regional Key office. Make sure that the person who signs this form is legally
authorized to represent the facility.
Name of Facility (As it appears on DPW Certificate of Compliance/Registration):
Address (As it appears on DPW Certificate of Compliance/Registration):
City/State:
Zip Code:
County:
MPI#
_______
Place checkmark () if the Regional Key should use the above as the Correspondence Address for this facility
Phone Number (where you care for the children): (
)
Contact Person:
Facility Type (Check one):
Ext.
Title:
Center
Fax: (
)
Email:
Family Day Care Home
Certificate of Compliance # (Centers/Groups Only):
Group Home
Is this a School Age Only site? Yes
Expiration Date:
No
SSN or FEIN (Family Only):
Legal Entity Name:
Address:
Phone Number:
City/State:
Zip Code:
Contact Person:
Place checkmark () if the Regional Key should use the above as the Correspondence Address for this facility
Phone Number: (
)
Ext.
Fax: (
)
Email:
If neither address should be used for correspondence, please write the preferred correspondence address on the bottom of this form.
Additional Facility Location
Name and MPI#
Address
City/State/
Zip Code
Email AddressREQUIRED
Phone #
Contact
Person’s Name
 Yes
 No 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.
Signature of the Individual Who is Legally Authorized to Represent the Facility
Date
Print Name
Title
APP-01
03/20/2013
KEYSTONE STARS ENROLLMENT APPLICATION
NON-DPW CERTIFIED/REGULATED FACILITIES
Instructions: Please complete this form. Make sure that the person who signs this form is legally authorized to represent the facility.
Return this form to the Regional Key office with a copy of your current license, if applicable.
Legal Entity Name: ______________________________________________
MPI# (if applicable/known)____________________________
Address: ________________________________________________________
City/State:___________________________ Zip Code:__________ County__________________ Contact Person:_________________________
Phone Number:(________________) Ext.__________ Fax: ______________ Email: _________________________ (Required)
Regional Key should use the Facility address or the  Legal Entity address for Correspondence. (Please check () appropriate box)
If neither address should be used for correspondence, please write the preferred correspondence address on the bottom of this form.
Facility Type:
 Head Start
Additional Facility
Location Name and
MPI# (if known)
 School District/LEA Pre-K Counts
Address
City/State/
Zip Code
 Private Academic Nursery School (submit license with application)
Email AddressREQUIRED
Phone #
Contact
Person’s
Name
(Attach additional sheet if more space is needed)
 I attest that this information is true, accurate and complete to the best of my knowledge.
Signature of the Individual Who is Legally Authorized to Represent the Facility
Date
Print Name
APP-01
03/20/2013
Title
# of
Children
Served