Interest Form 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. "*" indicates required fields Parent/Guardian InformationParent 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) Chuuk 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 No Email Preferred Contact Method* Phone Email Text message WhatsApp Are you willing to provide your address so we know which programs serve your area?* Yes No Parent Street Address Parent City Zip Code*Elementary school your child will attend (if you know) Child InformationChild Name* First name Last name(s) Child Birth Date* Month Day Year 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 No Is your child a member of a federally recognized tribe?* Yes No TribeBurns PaiuteConfederated Tribes of Coos, Lower Umpqua and Siuslaw IndiansConfederated Tribes of Grand RondeConfederated Tribes of SiletzConfederated Tribes of Umatilla ReservationConfederated Tribes of Warm SpringsCow Creek Band of Umpqua IndiansCoquille Indian TribeKlamath TribesHousehold InformationHousehold 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 No 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 No Are you a single parent? Yes No Optional Information: Needs and Preferences for PreschoolIdeal ScheduleDays of the week neededPlease check all that apply. Monday Tuesday Wednesday Thursday Friday Hours needed: from5:00 a.m.5:30 a.m.6:00 a.m.6:30 a.m.7:00 a.m.7:30 a.m.8:00 a.m.8:30 a.m.9:00 a.m.9:30 a.m.10:00 a.m.10:30 a.m.11:00 a.m.11:30 a.m.12:00 p.m.12:30 p.m.1:00 p.m.1:30 p.m.2:00 p.m.2:30 p.m.3:00 p.m.3:30 p.m.4:00 p.m.4:30 p.m.5:00 p.m.5:30 p.m.6:00 p.m.6:30 p.m.7:00 p.m.to5:00 a.m.5:30 a.m.6:00 a.m.6:30 a.m.7:00 a.m.7:30 a.m.8:00 a.m.8:30 a.m.9:00 a.m.9:30 a.m.10:00 a.m.10:30 a.m.11:00 a.m.11:30 a.m.12:00 p.m.12:30 p.m.1:00 p.m.1:30 p.m.2:00 p.m.2:30 p.m.3:00 p.m.3:30 p.m.4:00 p.m.4:30 p.m.5:00 p.m.5:30 p.m.6:00 p.m.6:30 p.m.7:00 p.m.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 No Preferred language(s) for instruction -- check all that apply American Sign Language (ASL) العربية الفصحى (Arabic) 广州话 [廣州話] (Cantonese) Chuuk 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 HomeAre there younger children in the home? No 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?* No Yes Name of person assisting with the form* Role or relationship to parent/guardian* Phone number to call with questions*Consent Agreement* I agreeI 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.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.VerificationEmailThis field is for validation purposes and should be left unchanged.