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

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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 ____________________________

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