Preschool Promise Screening Form English

 

Complete the following to determine which programs would be a good fit for your family.

On September 1, 2020 my child will be *Required
Are you interested in preschool programs in Umatilla, Union or Morrow counties *Required
Have you applied for a Head Start program? *Required

*this does not impact your eligibility into other programs

Is your annual family income at or below the 2020 Federal Poverty Level? (See chart at top of page) *Required
*Please Note:

Some programs offer services to foster children and families experiencing homelessness regardless of family income.

IF YOU ANSWER NO to any of the questions in this section, and you are not completing this application for a foster child or experiencing homelessness, you may not be eligible for free preschool.

Please email contact@bluemountainkids.org if you would like more information.

Parent/Guardian Contact Information

Parent's First Name

Parent's Middle Name

Parent's Last Name

Street, City, State, and Zip

How do you prefer to be contacted? *Required
What language do you prefer to be contacted in? *Required

Child's Information

Child's First Name

Child's Middle Name

Child's Last Name

Gender *Required
Does your child have any health, nutrition, behavioral or mental health concerns which require specialized supports? *Required
Does your family have an Individual Family Service Plan (IFSP) to support your child's development? *Required
What is your child's primary language? *Required

HOW DO YOU IDENTIFY YOUR CHILD'S RACE, ETHNICITY, TRIBAL AFFILIATION, COUNTRY OF ORIGIN, OR ANCESTRY (select all that apply)?

AMERICAN INDIAN or ALASKA NATIVE
NATIVE HAWAIIAN or PACIFIC ISLANDER
MIDDLE EASTERN/NORTHERN AFRICAN
ASIAN
HISPANIC or LATINO/A
BLACK OR AFRICAN AMERICAN
WHITE
OTHER CATEGORIES

Family Information

Family Information

Preliminary Income/Eligibility
Is this application for a Foster Child? *Required

Income will be verified for: wages, child support, unemployment, cash grants, TANF and SSI

Does your family receive any of the following services or forms of financial assistance?

Homeless

Do you consider your family to be homeless (see requirements below) *Required

A child may be considered homeless if the family meets one of the criteria of the McKinney-Vento Definition of ''Homeless'' - Subtitle B of Title VII of the McKinney-Vento Homeless Assistance Act (TitleX, Part C of the No Child Left Behind Act) defines ''homeless'' as follows:

1. sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason;
2. living in motels, hotels, trailer parks, or camping grounds due to the lack of alternative adequate accommodations;
3. living in emergency or transitional shelters;
4. abandoned in hospitals; or
5. awaiting foster care placement;
6. staying in a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings;
7. living in cars, parks, public spaces, abandoned buildings, substandard housing, bus or train stations, or similar settings; and
8. migratory children who are living in circumstances described above.

Early Care and Education Preferences

Location *Required
Preferred Setting for Preschool
Select up to THREE(3) participating Preschool Promise providers where you are interested in enrolling
Does your child need transportation? *Required
Would you like Home Visitation/Parenting support? *Required
Do you need before or after preschool care? *Required

Parent/Guardian Signature

By submitting this screening form, 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.

Print Name

Signature Date