First Name *Required

Middle Name

Last Name *Required

Date of Birth *Required

By submitting this documentation, I understand and agree that the information on this form may be shared with entities and individuals involved in the Preschool Promise Program, including preschool providers, Enrollment Committees, Early Learning Hubs, Education Service Districts, Head Starts, school districts and the Oregon Department of Education and its Early Learning Division, for the purpose of administering and evaluating the Preschool Promise Program.

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