Preschool Application

Child Information

Child First Name

Child Middle Name

Child Last Name

Child Date of Birth

Child Gender

Child's Primary Language

Other Child Language

What Language Do You Speak at Home?

Other Language Spoken at Home

Child's Race and Ethnicity

(check all that apply)

American Indian or Alaska Native

Asian

Black or African America

Hispanic or Latino/a

Middle Eastern/Northern African

Native Hawaiian or Pacific Islander

White

Other Categories

Do you consider your family to be homeless?

Yes

Does your family have an Individual Family Service Plan (IFSP) to support your child's development?

Yes

Does your child have any other health, nutrition, behavioral or mental health concern that requires specialized supports?

Yes

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

If yes, list the name of the program:

Parent/Guardian 1 Contact Information

First Name

Middle Name

Last Name

Relationship to Child

If Other Please Enter Relationship

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?

Other Contact Method

Parent/Guardian 1 Language

In what language do you prefer to receive written communication?

Other Written Contact Language

In what language do you prefer to receive verbal communication?

Other Verbal Contact Language

Parent/Guardian 1 Employment Status

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)

If Other Please Enter Relationship (Parent/Guardian 2)

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)

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)

Other Written Contact Language (parent/guardian 2)

In what language do you prefer to receive verbal communication? (parent/guardian 2)

Other Verbal Contact Language (Parent/Guardian 2)

Parent/Guardian 2 Employment Status

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

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