Albina Pre-Application

Application
For security purposes, please trace the line below
For This Application To Be Considered, Please Include The Following:

-->Child's Date of Birth and/or Proof of Pregnancy (if pregnant, and applying for Prenatal Services) AND

--> Last year's income (for both parents in the home) Tax return (must be signed), or copies of all W-2's, or a letter from DHS or Unemployment.

Services for Teen Parents are provided through partnership with Portland Public Schools. If you are a teen parent attending or planning to attend PPS, please email ehsfrontdesk@albinaheadstart.org or call 503-236-9389 to obtain information prior to completing this application.
My family is applying for (select all that apply):
- How many children (excluding prenatal) will be applying?
  If only applying for prenatal program enter 0
- If applying for Prenatal Services, What is your due date?
  
  MonthDayYear
  Date
- Child's Name
  
  First NameLast Name
- Child's Name (First Middle Last)
- Date of Birth
  
  MonthDayYear
  Date
- Gender
- Child lives with (check all that apply)
  
  Other, please specfy:
- Are both parents in the home?
- Does child have a DHS case worker?
  
  Yes, please provide name and phone number:
- Does child receive Multnomah Early Childhood Program services?
- Does child receive speech & hearing services?
- Does child receive Counseling services?
  
  Yes, please provide name and phone number:
- Has this child previously attended Early Head Start or Head Start?
- Which Program(s)?
- Child's Name
  
  First NameLast Name
- Child's Name (First Middle Last)
- Date of Birth
  
  MonthDayYear
  Date
- Gender
- Child lives with (check all that apply)
  
  Other, please specfy:
- Are both parents in the home?
- Does child have a DHS case worker?
  
  Yes, please provide name and phone number:
- Does child receive Multnomah Early Childhood Program services?
- Does child receive speech & hearing services?
- Does child receive Counseling services?
  
  Yes, please provide name and phone number:
- Has this child previously attended Early Head Start or Head Start?
- Which Program(s)?
- Child's Name
  
  First NameLast Name
- Child's Name (First Middle Last)
- Date of Birth
  
  MonthDayYear
  Date
- Gender
- Child lives with (check all that apply)
  
  Other, please specfy:
- Are both parents in the home?
- Does child have a DHS case worker?
  
  Yes, please provide name and phone number:
- Does child receive speech & hearing services?
- Does child receive Multnomah Early Childhood Program services?
- Does child receive Counseling services?
  
  Yes, please provide name and phone number:
- Has this child previously attended Early Head Start or Head Start?
- Which Program(s)?
- Parent/Guardian
  
  First NameLast Name
- Date of Birth
  
  MonthDayYear
  Date
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone
  Format: (000) 000-0000.
- Email
  example@example.com
- What is your first language?
- Do you need translation services?
- Is there a second parent or guardian to list on this application?
- Parent/Guardian
  
  First NameLast Name
- Date of Birth
  
  MonthDayYear
  Date
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone
  Format: (000) 000-0000.
- Email
  example@example.com
- What is their first language
- Do you need translation services?
- Income / Eligibility Information
  
  FAMILY means all persons living in the same household who are supported by the child's parent(s) or guardian(s) income; and are related to the child's parent(s) or guardian(s) by blood, marriage, or adoption; or are the child's authorized caregiver or legally responsible party.
  
  Please call 503-282-1975 or 503-236-9389 if you have questions.
- How many FAMILY members living in your home financially support your household (include yourself)?
- How many FAMILY members live in your home and you financially support (include yourself)?
- Homeless is defined According to section 725(2) of the McKinney-Vento Homeless Assistance Act (42 U.S.C. 11434a (2, the term "homeless children and youths" (A) means individuals who lack a fixed, regular, and adequate night time residence; and (B) includes (i) children and youths who are sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason; are living in motels, hotels, trailer parks, or camping grounds due to the lack of alternative accommodations; are living in emergency or transitional shelters; are abandoned in hospitals; or are awaiting foster care placement; (ii) children and youths who have 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; (iii) children and youths who are living in cars, parks, public spaces, abandoned buildings, substandard housing, bus or train stations, or similar settings; and (iv) migratory children who qualify as homeless for the purposes of this subtitle because the children are living in circumstances described in clauses (i) through (iii Children and youth are considered homeless if they fit both part A and any one of the subparts of part B of the definition above.
- Is your family currently homeless (refer to definition on previous slide)?
- Does your family currently receive assistance from DHS/TANF/SNAP?
- Does your family currently receive SSI (Social Security Income)?
- Does your family currently receive a child care subsidy or ERDC (Employment Related Daycare)?
- Are you currently working full time (at least 25 hours a week)?
- Does your family live in subsidized housing?
- Are you a current Albina Head Start/Early Head Start Employee?
- Are you or your child related to a current Albina Head Start Employee or Board member?
- Name of Albina employee or board member
  
  First NameLast Name
- Early Head Start Options
  Please number (1, 2, 3) beside your top three location preferences. We cannot guarantee you a spot at your chosen sites, we will try to accommodate your request.
  
  *Sites with both EHS and HS are Blank, Brown, McCormack, PCC and Young.
  Infant Classrooms are located at Blank, Brown, Gordly, McCormack, PCC, Talton (Faubion).
  PPS Teen Sites for Infant/Toddler are located at the following high schools: Grant, Roosevelt, Franklin, Marshall and McDaniel Early Head Start Center Based.
  
  Choice #Blank, Owen: 909 NE 52nd
  Choice #Brown, Richard: 605 NE Ivy
  Choice #Clarendon: 9325 N Van Houghton
  Choice #Franklin High School: 5405 SE Woodward
  Choice #Gordly, Avel: 911 N Skidmore
  Choice #Grant High School: 2245 NE 36th
  Choice #Highland 7600 NE Glisan
  Choice #McCormack Matthews*: 6930 N Kerby
  Choice #Hayu Alqi Uyxat PPS 01: 1530 NE Glisan
  Choice #McDaniel High School: 2735 NE 82nd Ave
  Choice #PCC SE Campus (PCC Students)
  Choice #Roosevelt High School: 6941 N. Central
  Choice #Rose, Traci: 4206 NE Garfield
  Choice #Talton, Carl (Faubion): 2930 NE Dekum
  Choice #Young, Carolyn*: 4219 NE MLK Jr.
- Early Head Start Options
  Please select your top three location preferences below. We cannot guarantee you a spot at your chosen sites, we will try to accommodate your request.
  
  *Sites with both EHS and HS are Blank, Highland, McCormack, PCC SE, PCC Cascade and White.
  
  Infant Classrooms are located at Blank, Brown, McCormack, PCC SE, PCC Cascade, Talton (Faubion), Young.
  
  PPS Teen Sites for Infant/Toddler are located at the following high schools: Grant, Franklin, Hayu and McDaniel Early Head Start Center Based.
- First Choice
- Second Choice
- Third Choice
- Head Start Options
  Please select your top three location preferences below. We cannot guarantee you a spot at your chosen sites, we will try to accommodate your request.
  
  *Sites with both EHS and HS are Blank, McCormack, PCC SE, PCC Cascade and White.
  
  **Sites that include Mandarin lessons
- First Choice
- Second Choice
- Third Choice
- Head Start Options
  Please number (1, 2, 3) beside your top three location preferences. We cannot guarantee you a spot at your chosen sites, we will try to accommodate your request.
  
  *Sites with both EHS and HS are Blank, Brown, McCormack, PCC and Young.
  
  Choice #Angelou, Maya: 4010 N Borthwick
  Choice #Lewis, Charlotte: 4919 NE 17th (Mandarin Instruction Included)
  Choice #Carlton Court: 5249 NE Killingsworth
  Choice #Clegg, Tina: 1425 NE Dekum (Mandarin Instruction Included)
  Choice #Garlington, Yvonne & John: 4514 SE Flavel Dr.
  Choice #Highland*: 7600 NE Glisan
  Choice #Lexington Court: 7858 SE 72nd
  Choice #McCormack Matthews*: 6930 N Kerby (Mandarin Instruction Included)
  Choice #PCC SE Campus Must be PCC Student
  Choice #Priestley, 6841 N Interstate
  Choice #Sylvia, Audrey: 241 N Alberta
  Choice #Waters, Gladys: 111 NE Failing (Mandarin Instruction Included)
  Choice #Young, Carolyn*: 4219 NE MLK Jr.
- How did you hear about our program?
- Please review before signing:
- File Upload
  
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- File Upload
  
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- I certify this information is true, if any part is false, my participation in the agency's programs may be terminated and I may be subjected to legal action. I hereby consent and agree to disclosure by Albina Head Start of the information provided and included with this application, or any summaries thereof or prepared or obtained by Albina Head Start, to any third party in connection with verification of the information provided, the eligibility of the child to receive services from Albina Head Start, or Albina Head Start's eligibility to participate in or take advantage of federal, state, or local programs.
- Parent/Guardian Signature
- Should be Empty: