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  • Early Childhood Education Interest Questions

  • Program location options

    Please list the locations you would like to have your child by order of priority:
  • What type of program(s) would you like to be considered for during the 2026-2027 school year?

  • Does a parent/guardian in your household receive any of the following?

  • Oregon Health Plan/YCCO*
  • TANF*
  • SNAP*
  • ERDC (Employment Related Day Care)*
  • WIC*
  • During the last two weeks, have either of the child's parents or guardians been bothered more than half the days by feeling down, depressed, hopeless, nervous, anxious or on edge?*

  • Household Income

  • Image field 585
  • Where did you hear about us?
  • Is this family working toward reunification with their child?
  • This applies to:
  • I am referring:

  • Child 1 Information

  • Child 1 Date of Birth*
     / /
  • Child 1 Gender*
  • What is your child's primary language? (Child 1) *
  • What language(s) do you speak at home? (Child 1)*

  • Child's Race and Ethnicity

    Select "Other Categories" to decline to answer or if unknown.
  • American Indian or Alaska Native (Child 1)*
  • American Indian or Alaska Native (Child 1) - Select all that apply.*
  • Native Hawaiian or Pacific Islander (Child 1)*
  • Native Hawaiian or Pacific Islander (Child 1) - Select all that apply.*
  • Middle Eastern / Northern African (Child 1)*
  • Middle Eastern / Northern African (Child 1) - Select all that apply.*
  • Asian (Child 1)*
  • Asian (Child 1) - Select all that apply.*
  • Hispanic or Latino/a (Child 1)*
  • Hispanic or Latino/a (Child 1) - Select all that apply.*
  • Black or African American (Child 1)*
  • Black or African American (Child 1) - Select all that apply.*
  • White (Child 1)*
  • White (Child 1) - Select all that apply.*
  • Other Categories (Child 1)*
  • Other Categories (Child 1) - Select all that apply.*
  • Is your child currently enrolled in a childcare/preschool program?*
  • Is this child in a state approved foster care placement?*
  • Does your child receive special education services, have an Individual Family Service Plan (IFSP), working with Early Intervention (EI), or Early Childhood Special Education (ECSE) to support your child’s development?*

  • Does your child require any of the following specialized supports (answer does not impact eligibility)?

  • Behavioral*
  • Health*
  • Mental Health*
  • Nutrition*
  • Add another child to the application?*

  • Child 2 Information

  • Child 2 Date of Birth*
     / /
  • Child 2 Gender*
  • What is your child's primary language? (Child 2)*
  • What language(s) do you speak at home? (Child 2)*

  • Child's Race and Ethnicity

    Select "Other Categories" to decline to answer or if unknown.
  • American Indian or Alaska Native (Child 2)*
  • American Indian or Alaska Native (Child 2) - Select all that apply.
  • Native Hawaiian or Pacific Islander (Child 2)*
  • Native Hawaiian or Pacific Islander (Child 2) - Select all that apply.
  • Middle Eastern / Northern African (Child 2)*
  • Middle Eastern / Northern African (Child 2) - Select all that apply.
  • Asian (Child 2)*
  • Asian (Child 2) - Select all that apply.
  • Hispanic or Latino/a (Child 2)*
  • Hispanic or Latino/a (Child 2) - Select all that apply.
  • Black or African American (Child 2)*
  • Black or African American (Child 2) - Select all that apply.
  • White (Child 2)*
  • White (Child 2) - Select all that apply.
  • Other Categories (Child 2)*
  • Other Categories (Child 2) - Select all that apply.
  • Is your child currently enrolled in a childcare/preschool program?*
  • Is this child in a state approved foster care placement?*
  • Does your child receive special education services, have an Individual Family Service Plan (IFSP), working with Early Intervention (EI), or Early Childhood Special Education (ECSE) to support your child’s development?*

  • Does your child require any of the following specialized supports (answer does not impact eligibility)?

  • Behavioral*
  • Health*
  • Mental Health*
  • Nutrition*
  • Add another child?

  • Legal Parent/Guardian 1 Information

  • Parent/Guardian 1 Date of Birth:
     - -

  • Parent/Guardian 1 Race and Ethnicity

    Select "Other Categories" to decline to answer or if unknown.
  • American Indian or Alaska Native (Parent/Guardian 1)*
  • American Indian or Alaska Native (Parent/Guardian 1)
  • Native Hawaiian or Pacific Islander (Parent/Guardian 1)*
  • Native Hawaiian or Pacific Islander (Parent/Guardian 1)
  • Middle Eastern / Northern African (Parent/Guardian 1)*
  • Middle Eastern / Northern African (Parent/Guardian 1)
  • Asian (Parent/Guardian 1)*
  • Asian (Parent/Guardian 1)
  • Hispanic or Latino/a (Parent/Guardian 1)*
  • Hispanic or Latino/a (Parent/Guardian 1)
  • Black or African American (Parent/Guardian 1)*
  • Black or African American (Parent/Guardian 1)
  • White (Parent/Guardian 1)*
  • White (Parent/Guardian 1)
  • Other Categories (Parent/Guardian 1)*
  • Other Categories (Parent/Guardian 1)
  • Relationship to Child(ren): (Parent/Guardian 1)*
  • Child(ren) lives with Parent/Guardian what percentage of time:*

  • Legal Parent/Guardian 1 Contact Information

  • Format: 000-000-0000.
  • Format: 000-000-0000.
  • How do you prefer to be contacted? (Parent/Guardian 1)*
  • What is your primary language? (for tracking purposes) (Parent/Guardian 1)*
  • In which language(s) do you prefer to receive written communication? (Parent/Guardian 1)*
  • In which language(s) do you prefer to receive verbal communication? (Parent/Guardian 1)*

  • Legal Parent/Guardian 1 Employment Status

  • Check all that apply (Parent/Guardian 1):*
  • Do you have another parent to add to the application?*
  • Parent/Guardian 1 Gender:
  • Due Date or Date of Arrival (if pregnant/expecting):
     / /

  • Legal Parent/Guardian 2 Information

  • Parent/Guardian 2 Relationship to child(ren):*
  • Child(ren) lives with Parent/Guardian what percentage of time(Parent/Guardian 2):*

  • Legal Parent/Guardian 2 Contact Information

  • Format: 000-000-0000.
  • Format: 000-000-0000.
  • Is the address the same as Parent/Guardian 1?*
  • How do you prefer to be contacted? (Parent/Guardian 2)*
  • What is your primary language? (for tracking purposes) (Parent/Guardian 2)*
  • In which language(s) do you prefer to receive written communication? (Parent/Guardian 2)*
  • In which language(s) do you prefer to receive verbal communication? (Parent/Guardian 2)*

  • Legal Parent/Guardian 2 Employment Status

  • Check all that apply (Parent/Guardian 2):*
  • Parent/Guardian 2 Date of Birth:
     - -
  • Parent/Guardian 2 Gender:

  • Parent/Guardian 2 Race and Ethnicity

    Select "Other Categories" to decline to answer or if unknown.
  • American Indian or Alaska Native (Parent/Guardian 2)*
  • American Indian or Alaska Native (Parent/Guardian 2)
  • Native Hawaiian or Pacific Islander (Parent/Guardian 2)*
  • Native Hawaiian or Pacific Islander (Parent/Guardian 2)
  • Middle Eastern / Northern African (Parent/Guardian 2)*
  • Middle Eastern / Northern African (Parent/Guardian 2)
  • Asian (Parent/Guardian 2)*
  • Asian (Parent/Guardian 2)
  • Hispanic or Latino/a (Parent/Guardian 2)*
  • Hispanic or Latino/a (Parent/Guardian 2)
  • Black or African American (Parent/Guardian 2)*
  • Black or African American (Parent/Guardian 2)
  • White (Parent/Guardian 2)*
  • White (Parent/Guardian 2)
  • Other Categories (Parent/Guardian 2)*
  • Other Categories (Parent/Guardian 2)
  • Is your family currently facing any of the following living situations: living in a shelter, staying in a motel or campground due to a lack of adequate housing, residing in a car, park, abandoned building, or bus/train station, double up (staying) with others due to housing loss or financial difficulties or Lacking a fixed, regular, and adequate place to stay at night?*

  • Child 3 Information

  • Child 3 Date of Birth*
     / /
  • Child 3 Gender*
  • What is your child's primary language? (Child 3)*

  • Child's Race and Ethnicity

    Select "Other Categories" to decline to answer or if unknown.
  • American Indian or Alaska Native (Child 3)*
  • American Indian or Alaska Native (Child 3) - Select all that apply.
  • Native Hawaiian or Pacific Islander (Child 3)*
  • Native Hawaiian or Pacific Islander (Child 3) - Select all that apply.
  • Middle Eastern / Northern African (Child 3)*
  • Middle Eastern / Northern African (Child 3) - Select all that apply.
  • Asian (Child 3)*
  • Asian (Child 3) - Select all that apply.
  • Hispanic or Latino/a (Child 3)*
  • Hispanic or Latino/a (Child 3) - Select all that apply.
  • Black or African American (Child 3)*
  • Black or African American (Child 3) - Select all that apply.
  • White (Child 3)*
  • White (Child 3) - Select all that apply.
  • Other Categories (Child 3)*
  • Other Categories (Child 3) - Select all that apply.
  • Add another child?

  • Child 4 Information

  • Child 4 Date of Birth*
     / /
  • Child 4 Gender*
  • What is your child's primary language? (Child 4)*

  • Child's Race and Ethnicity

    Select "Other Categories" to decline to answer or if unknown.
  • American Indian or Alaska Native (Child 4)*
  • Native Hawaiian or Pacific Islander (Child 4)*
  • Middle Eastern / Northern African (Child 4)*
  • Asian (Child 4)*
  • Hispanic or Latino/a (Child 4)*
  • Black or African American (Child 4)*
  • White (Child 4)*
  • Other Categories (Child 4)*
  • Other Categories (Child 4) - Select all that apply.
  • American Indian or Alaska Native (Child 4)
  • Native Hawaiian or Pacific Islander (Child 4)
  • Middle Eastern / Northern African (Child 4)
  • Asian (Child 4)
  • Hispanic or Latino/a (Child 4)
  • Black or African American (Child 4)
  • White (Child 4)

  • Child 5 Information

  • Child 5 Date of Birth*
     / /
  • Child 5 Gender*
  • What is your child's primary language? (Child 5)*
  • What language(s) do you speak at home? (Child 5)*

  • Child's Race and Ethnicity

    Select "Other Categories" to decline to answer or if unknown.
  • American Indian or Alaska Native (Child 5)*
  • Native Hawaiian or Pacific Islander (Child 5)*
  • Middle Eastern / Northern African (Child 5)*
  • Asian (Child 5)*
  • Hispanic or Latino/a (Child 5)*
  • Black or African American (Child 5)*
  • White (Child 5)*
  • Other Categories (Child 5)*
  • Other Categories (Child 5)
  • American Indian or Alaska Native (Child 5)
  • Native Hawaiian or Pacific Islander (Child 5)
  • Middle Eastern / Northern African (Child 5)
  • Asian (Child 5)
  • Hispanic or Latino/a (Child 5)
  • Black or African American (Child 5)
  • White (Child 5)
  • Add another child?

  • Child 6 Information

  • Child 6 Date of Birth*
     / /
  • Child 6 Gender*
  • What is your child's primary language? (Child 6)*
  • What language(s) do you speak at home? (Child 6)*

  • Child's Race and Ethnicity

    Select "Other Categories" to decline to answer or if unknown.
  • American Indian or Alaska Native (Child 6)*
  • Native Hawaiian or Pacific Islander (Child 6)*
  • Middle Eastern / Northern African (Child 6)*
  • Asian (Child 6)*
  • Hispanic or Latino/a (Child 6)*
  • Black or African American (Child 6)*
  • White (Child 6)*
  • Other Categories (Child 6)*
  • Other Categories (Child 6)
  • American Indian or Alaska Native (Child 6)
  • Native Hawaiian or Pacific Islander (Child 6)
  • Middle Eastern / Northern African (Child 6)
  • Asian (Child 6)
  • Hispanic or Latino/a (Child 6)
  • Black or African American (Child 6)
  • White (Child 6)

  • Select the category/categories that your request fits into the best:

  • What is the primary category of this request?

  • Which resources have you tried to access for assistance with this request?

  • YCAP*
  • Salvation Army*
  • Give A Little*
  • Habitat for Humanity*
  • NWSDS*
  • St. Vincent DePaul*
  • Yamhill County Health and Human Services*
  • ODHS*
  • Lutheran Community Services NW*
  • Local schools*
  • Local churches*
  • Has not sought assistance*
  • Other*

  • What is the family experiencing?

    Check all that apply.
  • Pregnancy/Expecting a new child
  • First Birth
  • Child or pregnant person has a medical condition
  • Feeding/weight gain problems
  • Developmental delay/diagnosed disability
  • Concerns about child's milestones
  • Parent with developmental delays
  • A parent under age 21
  • Maternal or paternal depression (baby blues)
  • Isolation/lack of support
  • Migrant/seasonal work
  • Substance abuse/recovery
  • A parent who is incarcerated or recently incarcerated
  • Concerns about violence or safety
  • Housing instability or homelessness
  • ODHS Child Welfare involved
  • Parent feeling down, depressed, hopeless, anxious, or on edge a majority of the last two weeks
  • Other

  • Family would like to learn more about:

    Check all that apply.
  • Infant/child nutrition
  • Parenting skills
  • Child development and milestones
  • Maternal or paternal depression support
  • Birth supports/doula services
  • Keeping my family safe
  • Substance abuse/recovery support
  • Connecting with other parents
  • Case management/care coordination
  • Quitting tobacco
  • Other

  • What other services/resources are the family already receiving?

  • Early Childhood Education Program
  • OHP/YCCO
  • SNAP
  • WIC
  • Is your agency interested in receiving Early Learning Hub program resources?*
  • When a staff member contacts your agency, are you the best contact? Select No if there is an alternate contact for this matter.
  • Format: (000) 000-0000.
  • Section 8 housing
  • SSI/SSD
  • Home Visiting program
  • Employment program
  • Family support program
  • Behavioral Health program
  • Early Childhood Education program
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Sector*

  • Eligibility Document Uploads

    Please use this section to upload copies of one of the eligibility document types in each category listed below. Eligibility documents are required to process the application.

  • For Household Income Verification:

    • Child Support Statements
    • Foster Child Documentation
    • Income Tax Form 1040 or 1040A
    • SNAP (dated within the last 12 months)
    • TANF (dated within the last 12 months)
    • Adult OHP, OHP Bridge, OHP CWM (dated within the last 12 months)
    • ERDC (must show calculated household income on benefit letter or you will be asked to provide a different income method)
    • WIC (must show calculated household income on benefit letter or you will be asked to provide a different income method)
    • Paystubs (3 most recent concurrent)
    • SSI Letter
    • Unemployment Statements
    • W2
    • Housing Adjustment
    • Family Income Supplemental Form
    • Other

    Child's Age Verification:

    • Copy of Birth Certificate
    • Copy of Hospital Record
    • Copy of Pediatrician/Doctor's Office Paperwork
    • Child's Immunization Record (must be from healthcare organization)
    • Health Insurance Documentation (must show birthday)
    • Foster Care Placement Letter
    • Legal Document (e.g benefits letter) that shows child's date of birth
    • PSP Date of Birth Supplemental Form

    *Please note that the document with footprints on it given by hospitals is not considered a birth certificate or legal document

    For Residence in Oregon Verification:

    • Current utility/service bill (electric, gas, water/sewer and waste)
    • Lease or rental agreement
    • Identification card or Oregon driver’s license
    • Paystub, 1040 tax form, or W2
    • Benefits letter (Social Security, TANF, SNAP, OHP letter, etc.) dated within the last 12 months
    • Foster care placement letter
    • Secure address through Address Confidentially Program
    • PSP Address Supplemental Form

    Important: PSP Eligibility specialists are required to keep copies of all documentation presented/used todetermine eligibility.

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  • Parent Consent - Yamhill Early Learning Hub

  • I give my permission for Yamhill CCO Early Learning Hub to share my name and contact information with the school districts, Head Start of Yamhill County, Migrant/Tribal Head Start, Yamhill County Public Health, or a Family Place Relief Nursery for referrals to their parenting and child health/preschool programs. I give my permission to receive information about assorted school readiness and family support opportunities through the Early Learning Hub and its partners.*

  • Parent Consent - Legal Parent / Guardian Signature

  • By signing this application, I confirm that I have given true and complete information, and I understand that the Oregon Department of Early Learning and Care may verify the information on this form. I understand that making false statements or intentionally omitting information may subject me to state and federal penalties. I understand PSP is a state funded program and preschool services provided under the PSP program may end if funds are no longer available.

    I understand and agree that the information on this form, any information gathered or collected by the provider as part of the Certification of Eligibility, and any tests or reports, describing my child’s educational progress in the PSP Program may be shared with entities involved in the delivery of PSP services and supports to my child, including but not limited to preschool providers, Enrollment Committees, Hubs, Education Service Districts (Early Childhood Special Education services), Child Care Resource & Referral and the Oregon Department of Early Learning and Care, for the purpose of administering and evaluating the PSP Program.

    Submission of this eligibility form is not a guarantee of admission into the PSP program.

    Legal Parent/Guardian
    Signature and Date Required

  • Date:*
     - -
  • Should be Empty: