Is Portland Niños right for me and my family?

1
Name* This field is required.
First Name
Middle Name
Last Name
2
Phone Number* This field is required.
Area Code
Phone Number
3
Email* This field is required.
example@example.com
4
What is your zip code?* This field is required.Hacienda CDC's Portland Niños program operates within Multnomah County limits.
97019 (Corbett)
97024 (Fairview)
97030 (Gresham)
97080 (Gresham)
97201 (Portland)
97202 (Portland)
97203 (Portland)
97204 (Portland)
97205 (Portland)
97206 (Portland)
97208 (Portland)
97209 (Portland)
97210 (Portland)
97211 (Portland)
97212 (Portland)
97213 (Portland)
97214 (Portland)
97215 (Portland)
97216 (Portland)
97217 (Portland)
97218 (Portland)
97219 (Portland)
97220 (Portland)
97221 (Portland)
97227 (Portland)
97230 (Portland)
97231 (Portland)
97232 (Portland)
97233 (Portland)
97236 (Portland)
97239 (Portland)
97266 (Portland)
97060 (Troutdale)
None of the above
5
Are you currently pregnant or have a child under the age of four?* This field is required.
YESNO
6
What is the age of your child?* This field is required.
We are expecting
0-4 years old
none of the above
7
Why are you interested in Sembrando Semillitas?* This field is required.
Early education for my child
I am a new parent
Access a network of support
Other
8
What is your household annual income range?* This field is required.Ex: $30,000
9
How many people are in your household?* This field is required.
10
Are you interested and able to participate in 2 home visits a month, virtually or in person?* This field is required.
YESNO
11
Would you prefer to engage and connect with other families virtually or in person?* This field is required.
Virtual
In-Person
Both
None of the above
12
How did you hear about us?
Word of Mouth
Online Search
Hacienda CDC website
I live in a Hacienda community
Direct Referral
Other
13
I would like to stay up to date and receive communications from Hacienda CDC.
YESNO
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