ERSEA (FSM) 03/04/2020 Copyright © 2011 Management Information Technology USA, Inc. 11.07.11
Mt. Hood Community College Child Development and Family Support Programs 10100 NE Prescott, Portland, OR 97220 ◊ (503) 491-6111 ◊ FAX (503) 491-6112
Early Head Start/Head Start Application
Family Information
Applicant (child applying for services)* First Middle Last Suffix Preferred
Name Birthday (MM/DD/YY) Gender SSN
___/___/___ M F
Race Hispanic English Proficiency Other Language Language Proficiency Child on OHP Asian Black White Multi-Racial
American Indian/Alaska Native
Hawaiian/Pac. IslanderOther:______________
Yes No
None Little Moderate Proficient
Little Moderate Proficient
Yes No
STAFF ONLY: EHS Transition Yes No CPID:
Applicant (child applying for services)* First Middle Last Suffix Preferred
Name Birthday (MM/DD/YY) Gender SSN
___/___/___ M F
Race Hispanic English Proficiency Other Language Language Proficiency Child on OHP Asian Black White Multi-Racial
American Indian/Alaska Native
Hawaiian/Pac. IslanderOther: _____________
Yes No
None Little Moderate Proficient
Little Moderate Proficient
Yes No
STAFF ONLY: EHS Transition Yes No CPID:
Parent/Guardian 1 First Middle Last Suffix Preferred Name Birthday (MM/DD/YY) Gender SSN
___/___/___ M F
Race Hispanic Relationship Status English Proficiency Other Language Language Proficiency Asian Black White Multi-Racial
American Indian/Alaska Native
Hawaiian/Pac.Islander Other: _____________
Yes No
Single Married Divorced Widowed
None Little Moderate Proficient
Little Moderate Proficient
Highest Grade Completed Employment Status Child's Relationship Custody Check all that apply: Grade: 11 or less High School Grad. GED College or Adv. Training Associates Bachelors Masters
Full Time Part Time Seasonal Unemployed Full Time & Training Part Time & Training Training or School Retired or Disabled
Biological/Adopted/Step Grandchild Niece/Nephew Foster Other ______________
Yes No
Provides Financial Support Teen Parent
If teen parent, subsidized? Yes No
Phone number: ( ) Cell Home Work Msg Is Adult Pregnant?
May we text this number? Yes No *standard text message rates may apply* Yes No
E-mail Address:Due Date:
Parent/ Guardian 2 First Middle Last Suffix Preferred Name Birthday (MM/DD/YY) Gender Living in home?
___/___/___ M F Yes No
Race Hispanic Relationship Status English Proficiency Other Language Language Proficiency Asian Black White Multi-Racial
American Indian/Alaska Native
Hawaiian/Pac.IslanderOther: ______________
Yes No
Single Married Divorced Widowed
None Little Moderate Proficient
Little Moderate Proficient
page 1
ERSEA (FSM) 03/04/2020 Copyright © 2011 Management Information Technology USA, Inc. 11.07.11
Parent/ Guardian 2 (continued) Highest Grade Completed Employment Status Child’s Relationship Custody Check all that apply:
Grade: 11 or less High School Grad. GED College or Adv. Training Associates Bachelors Masters
Full Time Part Time Seasonal Unemployed Full Time & Training Part Time & Training Training or School Retired or Disabled
Biological/Adopted/Step Grandchild Niece/Nephew Foster Other ______________
Yes No
Provides Financial Support Teen Parent
If teen parent, subsidized? Yes No
Phone number: ( ) Cell Home Work Msg Is Adult Pregnant?
May we text this number? Yes No *standard text message rates may apply* Yes No
E-mail Address:Due Date:
Family Living Address City State Zip
Mailing Address or Child Care Address (if different) City State Zip
Additional children/dependents living in the home (Non-Applicants)* First Middle Last Relationship Birthday (MM/DD/YY) Gender (Check)
1. ____/____/____ M F
2. ____/____/____ M F
3. ____/____/____ M F
4. ____/____/____ M F
Total # in the Family: _______
* If a family has more than two children applying for services, or more than 4 additional/non-applicant children, please complete aseparate copy of this for just the additional children; on the separate copy, do not complete the Adult, General Info, Family Income,or Family Interest sections.
Additional Contacts: In case we cannot get ahold of you Name Phone number Type Relationship to adult
( ) Cell Home Work Msg( ) Cell Home Work Msg
General Information Parental Status
(check one) Primary Language
at Home Receiving
WIC Active Military
Family Veteran Status
Referred by Child Welfare Agency
Receiving SNAP
1 Parent 2 Parents Yes No Yes No Yes No Yes No Yes No
DHS Child Protective Services
Caseworker First Last Phone
DHS Office. (Check One): East Midtown Alberta Gresham Other ________________________________
How did you hear about us? (Check one) Family/friend Social Media Event Flyer/poster Phone Call School Agency Referral______________ Other_____________
Certification: I certify this information is true. If any part is false, my participation in this agency’s programs may be terminated; and, I may be subject to legal action. I also understand the information in this application will be held in strict confidence within the agency and is accessible to me during normal business hours.
Parent/Guardian Signature ___________________________________________________ Date ____________________________
page 2