Harley's House Parent Consent Form

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We are glad you contacted us for help! The mission of Harley’s House is to strengthen families by providing support and childcare to families in Western Oklahoma with young children.

Acceptance into Harley’s House will be made on a case by case basis, based on minimum criteria, funding availability, and Board of Director (s) Approval *

Eligibility for program:

Oklahoma Resident

Child(ren) in home age 0-3 years and/or pregnant

Child(ren) currently lives with you

Willing to meet with Board of Directors

*Applications will be reviewed within 7 days. Follow-up will include a text to the number on application submission for next steps.

**If you need emergency childcare, please contact the hotline at 580-890-7185 or message us on Facebook**

CLICK NEXT BELOW TO CONTINUE
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Parent/Guardian/Caregiver Name* This field is required.
First Name
Last Name
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Parent/Guardian/Caregiver Date of Birth* This field is required.
Date
Month
Day
Year
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Parent/Guardian/Caregiver Cell Phone* This field is required.
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Parent/Guardian/Caregiver Email
example@example.com
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Race
Asian
Pacific Islander
White or Caucasian
Multi-racial
Native Hawaiian
American Indian/Alaskan Native
Black/ African American
Other
Prefer not to answer
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Ethnicity
Hispanic or Latino
Non-Hispanic/Latino
Prefer not to answer
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Language
English
Spanish
Arabic
Chinese
French
Italian
Japanese
Korean
Maori
Polish
Russian
Tagalog
Vietnamese
Tribal languages
English and Other (equally)
English and Spanish (equally)
Unknown/did not report
Other
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Check all of the circumstances that describe you
Prenatal
Postnatal (delivered in the past 12 mo.)
Primary Caregiver (child 0 – 3 yrs)
Breastfeeding
Other
Prefer not to answer
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What services and/or resources are you here for today?*Harley’s House is not able to provide housing or household items but can connect you with additional resource providers. Our primary focus includes childcare assistance, diapers, wipes & formula.
Health Care (OBYGN, pediatrician, etc.)
Health Insurance
Mental Health Services
Substance Use Services
Domestic/Interpersonal
Violence
Social Security/Disability
Hygiene Items
Household Items
Diaper/Wipes
Legal Aid
Childcare
Parenting Classes/Education
Adoption Services
Tobacco Cessation
Child Development
Rent/Utility
Housing/Shelter
Transportation
Food/Nutrition/Formula
SNAP/WIC
Clothing
Furniture
Safe Sleep
Car Seat
Home visitation
Education/GED
Employment/Job Training
Other
Prefer not to answer
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Which Resources are you currently receiving/using?
Food Bank
WIC
DHS Daycare Subsidy
SNAP
Diaper Bank
TANF
Other
Prefer not to answer
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In the past year, have you or any family members you live with been unable to get any of the following when it was really needed? (Check all that apply)
Food
Utilities
Clothing
Child Care
Transportation
Internet/Wireless access
Prenatal Appointments
Medicine or Any other Health Care (Medical, Dental, Mental Health, Vision)
Required Documents (Birth Certificate, Social Security Care, ID, etc.)
Phone
Prefer not to answer
Other
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What is your housing situation today (check all that apply)
I have housing
I do not have housing (staying with others/hotel/shelter/car/etc)
I am worried about losing my housing
Prefer not to answer
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What is your insurance?
Tricare
Medicaid
Medicare
CHIP
Tribal Insurance
Private Insurance
Other Public Insurance
Other
Not insured
Prefer to not answer
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How often do you see or talk to people that you care about and feel close to? (For example: talking/visiting friends or family, going to church or club meetings):
Less than once a week
1 – 2 times a week
3 – 5 times a week
5 or more times a week
Prefer not to answer
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Are you employed?* This field is required.
YESNO
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Employer Information
Employer (Business Name)
Employer Phone #
Employer Location (City)
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Are you pregnant?
YESNO
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Approximate Date of Birth for your pregnancy?
Date
Year
Month
Day
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How many children need assistance?Total # of children needing help
1 Child
2 Children
3 Children
4 Children
5 Children
6 Children
More than 6
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How many children are living in the home* This field is required.INCLUDING CHILDREN NEEDING ASSISTANCE
1
2
3
4
5
6
6+
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Child 1 Name
First Name
Last Name
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Child 1 Gender
Boy
Girl
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Child 1 Date of Birth* This field is required.
Date
Month
Day
Year
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Child 1 Sizes
Diaper Size
Clothing Size
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Child 2 Name
First Name
Last Name
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Child 2 Gender
Boy
Girl
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Child 2 Date of Birth* This field is required.
Date
Month
Day
Year
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Child 2 Sizes
Diaper Size
Clothing Size
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Child 3 Name
First Name
Last Name
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Child 3 Gender
Boy
Girl
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Child 3 Date of Birth* This field is required.
Date
Month
Day
Year
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Child 3 Sizes
Diaper Size
Clothing Size
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Child 4 Name
First Name
Last Name
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Child 4 Gender
Boy
Girl
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Child 4 Date of Birth* This field is required.
Date
Month
Day
Year
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Child 4 Sizes
Diaper Size
Clothing Size
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Child 5 Name
First Name
Last Name
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Child 5 Gender
Boy
Girl
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Child 5 Date of Birth* This field is required.
Date
Month
Day
Year
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Child 5 Sizes
Diaper Size
Clothing Size
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Child 6 Name
First Name
Last Name
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Child 6 Gender
Boy
Girl
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Child 6 Date of Birth* This field is required.
Date
Month
Day
Year
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Child 6 Sizes
Diaper Size
Clothing Size
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Do you need help with childcare?* This field is required.
YESNO
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Needs for Days/HoursEx: 9am to 11am
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
Hours Needed
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Hours Needed
Mon
Row 0, Column 0
Tues
Row 0, Column 1
Wed
Row 0, Column 2
Thurs
Row 0, Column 3
Fri
Row 0, Column 4
Sat
Row 0, Column 5
Sun
Row 0, Column 6
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What you are needing assistance with today?* This field is required.Ex: Diapers, Wipes, Formula, Childcare
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Tell us your story so we can help!* This field is required.
Huge
Large
Normal
Small
Ok
Ok
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How did you hear about us?* This field is required.
Friend/Family
Social Media
DHS
Church
TANF Worker
Web Search
YMCA
Work Ready Oklahoma
Connections
Health Department
School
Other
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Church
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Terms & Conditions* This field is required.
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Signature* This field is required.
Clear
55
BlueBot
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BlueBot Email
example@example.com
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Type a question
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Type a question
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