Interest Form

Need help choosing a preschool?

Fill out this form to tell us about your family, and we’ll get back to you shortly. If you have any trouble filling out the form, you can call 503-967-1187.

Please note that this is NOT an application.

If you already know which preschool you'd like your child to attend, please go to our Directory page to get to the application for that program.

"*" indicates required fields

Parent/Guardian Information

Parent or Guardian Name*

First name Last name(s)

Parent or Guardian Preferred Language*

Other Language

Phone*

OK to Text?*

Yes

Preferred Contact Method*

Phone

Text message

Are you willing to provide your address so we know which programs serve your area?*

Yes

Parent Street Address

Parent City

Zip Code*

Elementary school your child will attend (if you know)

Child Information

Child Name*

First name Last name(s)

Child Birth Date*

Please note that children need to have been born in 2017, 2018, or 2019 to be eligible for preschool programs beginning fall 2022.

Is this child currently in foster care?*

Yes

Is your child a member of a federally recognized tribe?*

Yes

Tribe

Household Information

Household Size:

Parents/Guardians*

Please enter a number from 1 to 10.

Children or other Dependents*

Please enter a number from 1 to 10.

Is agriculture or farm work (crops, nurseries, tree farms, canneries, dairy, livestock, fish, or bees) the primary source of your family’s income?*

Yes

Please check a box or boxes below if your family receives any of the following benefits.

Temporary Assistance for Needy Families (TANF)

Supplemental Nutrition Assistance Program (SNAP, or food stamps)

Women Infants & Children (WIC)

Oregon Health Plan (adult)

Supplemental Security Income (SSI)

Unemployment

Estimated combined income before taxes and deductions:

Select the frequency that applies

Could your family be considered housing insecure?*

Yes

Are you a single parent?

Yes

Optional Information: Needs and Preferences for Preschool

Ideal Schedule

Days of the week needed

Please check all that apply.

Monday

Tuesday

Wednesday

Thursday

Friday

Hours needed: from

Preferred location(s)

Location: Other

Will you be able to transport your child to and from the preschool?

Yes

Preferred language(s) for instruction -- check all that apply

*Please note that while instruction is not yet available in all languages, we encourage you to select the ideal format for your child so that we can document the need for additional programming.

Preferred language for instruction: Other

Optional Information: Younger Children in the Home

Are there younger children in the home?

Yes

Currently expecting (pregnant)

When is your due date?

May we contact you about your newborn or infant?

Yes, please contact me about nurse home visiting for my newborn or infant.

No, do not contact me about nurse home visiting for my newborn or infant.

Name of younger child

First Last name(s)

Younger child birthdate

Name of younger child

First Last name(s)

Younger child birthdate

Consent / Release of Information:

Are you assisting a parent/guardian with completion of this form, or completing it on their behalf?*

Yes

Name of person assisting with the form*

Role or relationship to parent/guardian*

Phone number to call with questions*

Signature - Full Legal Name*

By signing below, I attest that I am the custodial parent or legal guardian of the child named above and have the authority to submit this form on their behalf OR that I am assisting with the completion of this form upon direction of the parent/guardian indicated above and that I have obtained verbal consent to do so in their name.

Verification

Name

This field is for validation purposes and should be left unchanged.