Preschool Application
Child Information
Child First Name
Child Middle Name
Child Last Name
Child Date of Birth
Child Gender
Male
Female
No elements found. Consider changing the search query.
List is empty.
Child's Primary Language
English
Spanish
Russian
Vietnamese
Mandarin
Cantonese
Other
No elements found. Consider changing the search query.
List is empty.
Other Child Language
What Language Do You Speak at Home?
English
Spanish
Russian
Vietnamese
Chinese
Other
No elements found. Consider changing the search query.
List is empty.
Other Language Spoken at Home
Child's Race and Ethnicity
(check all that apply)
American Indian or Alaska Native
American Indian
Alaska Native
Canadian Inuit, Metis, or First Nation
Indigenous Mexican, Central American or South American
No elements found. Consider changing the search query.
List is empty.
Asian
Asian Indian
Chinese
Filipino/a
Hmong
Japanese
Korean
Laotian
South Asian
Vietnamese
Other Asian
No elements found. Consider changing the search query.
List is empty.
Black or African America
African American
African (Black)
Caribbean (Black)
Other Black
No elements found. Consider changing the search query.
List is empty.
Hispanic or Latino/a
Hispanic or Latino/a Central American
Hispanic or Latino/a Mexican
Hispanic or Latino/a South American
Other Hispanic or Latino/a
No elements found. Consider changing the search query.
List is empty.
Middle Eastern/Northern African
Northern African
Middle Eastern
No elements found. Consider changing the search query.
List is empty.
Native Hawaiian or Pacific Islander
Guamanian or Chamorro
Micronesian
Native Hawaiian
Samoan
Tongan
Other Pacific Islander
No elements found. Consider changing the search query.
List is empty.
White
Eastern European
Slavic
Western European
White/Caucasian
Other White
No elements found. Consider changing the search query.
List is empty.
Other Categories
Other (Please list)
Don’t know/Unknown
Decline/Don’t want to answer
No elements found. Consider changing the search query.
List is empty.
Do you consider your family to be homeless?
Yes
No
Does your family have an Individual Family Service Plan (IFSP) to support your child's development?
Yes
No
Does your child have any other health, nutrition, behavioral or mental health concern that requires specialized supports?
Yes
No
If yes, please list any health partners, ECSE specialist, or other providers you would like us to know about:
Is your child currently enrolled in a preschool program?
Yes
No
If yes, list the name of the program:
Parent/Guardian 1 Contact Information
First Name
Middle Name
Last Name
Relationship to Child
Parent
Legal Guardian
Foster Parent
Other
No elements found. Consider changing the search query.
List is empty.
If Other Please Enter Relationship
Child lives with Parent/Guardian what percentage of time:
0%
1 to 25%
26 to 50%
51 to 74%
75 to 99%
Parent/Guardian 1 Information Continued
Primary Phone
Secondary Phone
Email
*
Mailing Address
City
Zip Code
Physical Address (if different):
Physical Address City
Physical Address Zip Code
How do you prefer to be contacted?
Primary Phone
Secondary Phone
Email
Other
No elements found. Consider changing the search query.
List is empty.
Other Contact Method
Parent/Guardian 1 Language
In what language do you prefer to receive written communication?
English
Spanish
Russian
Vietnamese
Mandarin
Cantonese
No elements found. Consider changing the search query.
List is empty.
Other Written Contact Language
In what language do you prefer to receive verbal communication?
English
Spanish
Russian
Vietnamese
Chinese
Other
No elements found. Consider changing the search query.
List is empty.
Other Verbal Contact Language
Parent/Guardian 1 Employment Status
Parent/Guardian 1 Employment Status
Employed PT/FT
Student
Unemployed
Business Owner
Other
No elements found. Consider changing the search query.
List is empty.
Other Employment Status (Parent/Guardian 1)
Parent/Guardian 2 Information
Parent/Guardian 2 First Name
Parent/Guardian 2 Middle Name
Parent/Guardian 2 Last Name
Relationship to Child (Parent/Guardian 2)
Parent
Legal Guardian
Foster Parent
Other
No elements found. Consider changing the search query.
List is empty.
If Other Please Enter Relationship (Parent/Guardian 2)
Child lives with Parent/Guardian what percentage of time (Parent/Guardian 2):
0%
1 to 25%
26 to 50%
51 to 74%
75 to 99%
100%
Parent/Guardian 2 Contact Information
Primary Phone (Parent/Guardian 2)
Secondary Phone (Parent/Guardian 2)
Email (Parent/Guardian 2)
Mailing Address (Parent/Guardian 2)
City (Parent/Guardian 2)
Zip Code (Parent/Guardian 2)
Physical Address (Parent/Guardian 2)
Physical Address City (Parent/Guardian 2)
Physical Address Zip Code (Parent/Guardian 2)
How do you prefer to be contacted (Parent/Guardian 2)
Primary Phone
Secondary Phone
Email
Other
No elements found. Consider changing the search query.
List is empty.
Other Contact Method Please Enter (Parent/Guardian 2)
Parent/Guardian 2 Language
In what language do you prefer to receive written communication (parent/guardian 2)
English
Spanish
Russian
Vietnamese
Chinese
Other
No elements found. Consider changing the search query.
List is empty.
Other Written Contact Language (parent/guardian 2)
In what language do you prefer to receive verbal communication? (parent/guardian 2)
English
Spanish
Russian
Vietnamese
Chinese
Other
No elements found. Consider changing the search query.
List is empty.
Other Verbal Contact Language (Parent/Guardian 2)
Parent/Guardian 2 Employment Status
Parent/Guardian 2 Employment Status
Employed PT/FT
Student
Unemployed
Business Owner
Other
No elements found. Consider changing the search query.
List is empty.
Other Employment Status (Parent/Guardian 2)
Parent/ Guardian Signature
By signing this application, I confirm that I have given true and complete information and I understand that the Oregon Department of Education and its Early Learning Division may verify the information on this form. I understand that making false statements or intentionally omitting information may subject me to state and federal penalties. I understand Preschool Promise is a state funded program and preschool services provided under the Preschool Promise program may end if funds are no longer available. I understand and agree that the information on this form and any tests or reports describing my child’s educational progress in the Preschool Promise Program may be shared with entities and individuals involved in the Preschool Promise Program, including preschool providers, Enrollment Committees, Early Learning Hubs, Education Service Districts and the Oregon Department of Education and its Early Learning Division, for the purpose of administering and evaluating the Preschool Promise Program.
Submission of this eligibility form is not a guarantee of admission into the Preschool Promise program. Parent/Guardian Signature and Date Required.
Print Name
Signature
Clear
Today's Date