Please Complete this Form

Are you interested in preschool programs in Eastern Oregon? *

Yes

Preschool Preferences

Will your child be 2, 3 or 4 years old by September 1?

Which School Year Are You Applying For?

2024/2025 (current year)

2025/2026

Which County? *

Malheur

Baker

Wallowa

If you answered yes to any of the questions in this section, you may be eligible for free preschool and community resources. Please fill in as much of the following information you feel comfortable in completing. Thank you.

Preschool Preferences Continued

Malheur County - Rank up to three participating providers where you are interested in enrolling:

First Preschool Preference

Second Preschool Preference

Third Preschool Preference

Preschool Preferences Continued

Baker County - Rank up to three participating providers where you are interested in enrolling:

First Preschool Preference

Second Preschool Preference

Third Preschool Preference

Preschool Preferences Continued

Wallowa County - Rank up to three participating providers where you are interested in enrolling:

First Preschool Preference

Second Preschool Preference

Third Preschool Preference

Preferences

Do you have a preschool preference not listed on the previous page?

Parent/Guardian Contact Information

First Name *

Middle Name

Last Name *

Relationship to Child

Parent/Guardian Information

Primary Phone *

Secondary Phone

Email *

Address

City

State

Zip Code

Contact Preferences

How do you prefer to be contacted?

Other Contact Method

What language do you prefer to be contacted in?

Child #1 Information

Child First Name *

Child Last Name *

Child Date of Birth *

Child Gender *

Child's Primary Language *

Other Child Language

Is this child currently enrolled in a preschool program?

Yes

If yes, list the name of the program:

Child #2 Information

Child #2 First Name

Child #2 Last Name

Child #2 Date of Birth

Child #2 Gender

Child #2 Primary Language

Child #2: Other Language

Child #2: Is this child currently enrolled in a preschool program?

Yes

Child #2: If yes, list the name of the program

Parent/ Guardian Signature

By signing this screening form, I understand and agree that the information on this form may be shared with entities and individuals involved in the Coordinated Enrollment Networks, including preschool providers, Preschool Promise programs, Early Learning Hubs, Education Service Districts, Child Care Resource & Referral, Public School Districts, Oregon Pre-Kindergarten and Federal Head Start Programs, for the purpose of matching families with services and programs that best meet the needs of children at the family request.

I am (the person submitting this form):

If completing this form for the parent you must check here:

The family has given permission for their information to be submitted.

Print Name *

Signature *

Clear

Today's Date *

By checking this box you are consenting to receiving sms communications from Eastern Oregon Kids and Care. Standard data rates and charges apply. Text STOP to cancel your SMS communications.