1
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 ONLYDate Received: ______
Start Date: ______
Enrollment Approved by:______
Program Director ONLY
Today’s Date: ______/ INTAKE STAFF ONLY
Staff Initials: ______
New Student: ______
Returning Student: ______
Preferred Center:
1. ______
2. ______
A.M. ______
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
IE OI WL Date: ______Assigned to: ______
PARENT/GUARDIANINFORMATION
Parent/Guardian Name: ______DOB: ______
Gender: M F Address: ______
Phone Number(s): ______, ______
Primary Language Spoken in the Home: ______
E-mail Address: ______
Race(circle ONE): Race: Asian Black White American/Alaska Native Multi-Racial
Hawaiian/Pacific Islander Refused Unknown Other
Ethnicity: Latino/Hispanic Yes No
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): ______, ______
Primary Language Spoken in the Home: ______
E-mail Address: ______
Race(circle ONE): Race: Asian Black White American/Alaska Native Multi-Racial
Hawaiian/Pacific Islander Refused Unknown Other
Ethnicity: Latino/Hispanic Yes No
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): ______
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______
Parent/Guardian Signature______Date______
Approved on: 4/27/2016