Please Complete this Form

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

Are you interested in preschool programs in Eastern Oregon? *

Yes

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.

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

Preferences

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

First Preschool Preference

Second Preschool Preference

Third Preschool Preference

Preschool Preference Not Listed Above

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 *

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