How Did You Hear About Neighborhood House: ______

6650 SW Capital Hwy Portland, OR 97219 PH: 503-246-1663 x7302/FX: 503-244-180 INTAKE APPLICATION This application DOES NOT GUARANTEE ENROLLMENT. You will be notified regarding the results of your application

ERSEA USE ONLY INTAKE STAFF ONLY

Date Received: ______Staff Initials: ______Start Date: ______New Student: ______Enrollment Approved by:______Returning Student: ______Program Director Preferred Center: ONLY 1. ______2. ______A.M. ______Today’s Date: ______P.M. ______Full Day: ______Today’s Date: ______

How did you hear about Neighborhood House: ______

CHILD INFORMATION

Child’s Name: ______DOB: ______

Gender: M F Applying for: EHS HS

Primary Language Spoken in the Home: ______

Race: Asian Black White American/Alaska Native Multi-Racial

Hawaiian/Pacific Islander Refused Unknown Other

Ethnicity: Latino/Hispanic Yes No

Has this child previously attended EHS, HS or PP Program: Yes No

If yes, which program: EHS HS PP Foster Child? Yes No

Disability or Health Impairment: Yes No

If yes, what type: ______

Early Intervention / Special Education Services: Yes No

Which of the following phrases describe your child’s behaviour:

Shy Outgoing High Energy Easy Going Gets Frustrated Easily Independent

Approved on: 4/27/2016 2

IE OI WL Date: ______Assigned to: ______

PARENT/GUARDIAN INFORMATION

Parent/Guardian Name: ______DOB: ______

Gender: M F Address: ______

Phone Number(s): ______, ______

E-mail Address: ______

Race (circle ONE): Race: Asian Black White American/Alaska Native Multi-Racial

Marital Status (circle ONE): Single Married Separated Divorced Widowed

Custody: Yes No Teen Parent: Yes No Highest Level of Education: ______

Employment Status: ______Attending School: Yes No

Parent/Guardian Name: ______DOB: ______

Gender: M F Address: ______

Phone Number(s): ______, ______

E-mail Address: ______

Race (circle ONE): Race: Asian Black White American/Alaska Native Multi-Racial

Marital Status (circle ONE): Single Married Separated Divorced Widowed

Custody: Yes No Teen Parent: Yes No Highest Level of Education: ______

Employment Status: ______Attending School: Yes No

HOUSEHOLD INFORMATION

Living Address: ______Phone numbers: ______

Mailing Address (if different): ______

6650 SW Capital Hwy Portland, OR 97219 PH: 503-246-1663 x7302/FX: 503-244-180 INTAKE APPLICATION Parental Status (circle ONE): One parent Two parent Guardian(s)

Homeless Family: Yes No Foster Family: Yes No

Number of People in Household: ______Number of Family Members in Household: ______

FAMILY CIRCUMSTANCES EHS/HS ONLY

Disabled family Member Yes No Domestic Violence Yes No

Immigrant/Refugee Family Yes No Substance Abuse/ Recovery Yes No

Subsidized Housing Yes No DHS referral Yes No

Previous Foster Care: Yes No

Parent/Guardian Incarceration/Probation Yes No

Child Abuse or Neglect (prenatal exposure to drugs/Alcohol/Tobacco) Yes No

INCOME/ ELIGIBILITY INFORMATION

Current Annual Income (Approximately): ______

Current Monthly Income (Approximately): ______

DOES YOUR FAMILY RECEIVE ANY OF THE FOLLOWING? EHS/HS ONLY

TANF: Yes No SNAP: Yes No Supplemental Security Income: Yes No WIC: Yes No ERDC: Yes No OHP: Yes No

FAMILY EMERGENCY NEEDS

Food Yes No Clothing Yes No Health Care Yes No Housing Yes No

Utilities Yes No Child Support Yes No Protective Services Yes No Other:______Resources provided: ______

CERTIFICATION

I certify that this information is true. If any part is false, my participation in this agency’s program may be terminated and I may be subject to legal action. I also understand that the information in this application will be held in strict confidence within the agency and is accessible to me during normal hours.

Parent/Guardian Signature______Date______

Approved on: 4/27/2016