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

Company

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

Parent/Guardian Information

Parent or Guardian Name*

First name Last name(s)

Parent or Guardian Preferred Language*

American Sign Language (ASL)

العربية الفصحى (Arabic)

广州话 [廣州話] (Cantonese)

Chuukese

درى (Dari)

English

Français

Hindustani

Italiano

Kirinit

한국어 (Korean)

Qyol Mam

普通话 [普通話] (Mandarin)

Kajin M̧ajeļ

Tu'un Sávi

Nāhuatl

پښتو (Pashto)

Lokaiahn Pohnpei

Русский язык (Russian)

af Soomaali (اَف صَومالي˜)

Español

Kiswahili

українська мова (Ukrainian)

اُردُو (Urdu)

Tiếng Việt

Other

Other Language

Phone*

*OK to Text?*

Yes

Preferred Contact Method*

Phone

Text message

Would you like to be notified when the applications become available?*

Yes, notify me when the application for next school year (2026-2027) becomes available

Yes, I'm interested in both the current and next school year

No, I do not want to receive notifications

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*

Month

Day

Year

Please note that children need to have been born in 2021, 2022, or 2023 to be eligible for preschool programs beginning fall 2026.

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

Weekly

Every two weeks

Twice a month

Monthly

Yearly

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

Which program(s) are you interested in? (Select all that apply):

Preschool Promise

Head Start

Oregon PreKindergarten

Early Head Start

Not sure yet

Preferred location(s)

Aumsville

Brooks

Dallas

Gervais

Grand Ronde

Independence

Keizer

Lebanon

Monmouth

Salem

Silverton

Stayton

Sublimity

Turner

Woodburn

Other

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

American Sign Language (ASL)

العربية الفصحى (Arabic)

广州话 [廣州話] (Cantonese)

Chuukese

درى (Dari)

English

Français

Hindustani

Italiano

Kirinit

한국어 (Korean)

Qyol Mam

普通话 [普通話] (Mandarin)

Kajin M̧ajeļ

Tu'un Sávi

Nāhuatl

پښتو (Pashto)

Lokaiahn Pohnpei

Русский язык (Russian)

af Soomaali (اَف صَومالي˜)

Español

Kiswahili

українська мова (Ukrainian)

اُردُو (Urdu)

Tiếng Việt

Other

*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?

Month

Day

Year

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

Month

Day

Year

Name of younger child

First Last name(s)

Younger child birthdate

Month

Day

Year

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*

Consent Agreement*

I agree

I agree that the information I have provided on this form will be entered into a password-protected database and may be accessed by entities and individuals involved in regional publicly-funded early education programs, including Preschool Promise, Head Start, Early Head Start, Oregon PreKindergarten, tribal programs, and school districts for the purpose of sharing application, eligibility, and enrollment information with me.

*SMS Consent

I agree

By providing your phone number, you agree to be contacted by Marion & Polk Early Learning Hub and partner early learning programs by phone, text message, or email regarding preschool opportunities, enrollment, and available services.

Message frequency may vary. Message and data rates may apply. You can reply STOP to opt out of text messages at any time or HELP for more information. Your information will only be shared with partner programs to help connect you to preschool and early learning services. You may review our Privacy Policy to learn how your data is used.

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.

Your Name
Your Name
Your Name

Verification

Need Help Choosing a Preschool?

Need Help Choosing a Preschool?

Parent/Guardian Information

Child Information

Household Information

Household Size:

Optional Information: Needs and Preferences for Preschool

Ideal Schedule

Optional Information: Younger Children in the Home

Consent / Release of Information:

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