ERSEA (FSM) 03/04/2020 Copyright © 2011 Management Information Technology USA, Inc. 11.07.11 Mt. Hood Community College Child Development and Family Support Programs 10100 NE Prescott, Portland, OR 97220 ◊ (503) 491-6111 ◊ FAX (503) 491-6112 Early Head Start/Head Start Application Family Information Applicant (child applying for services)* First Middle Last Suffix Preferred Name Birthday (MM/DD/YY) Gender SSN ___/___/___ M F Race Hispanic English Proficiency Other Language Language Proficiency Child on OHP Asian Black White Multi-Racial American Indian/ Alaska Native Hawaiian/Pac. Islander Other:______________ Yes No None Little Moderate Proficient Little Moderate Proficient Yes No STAFF ONLY: EHS Transition Yes No CPID: Applicant (child applying for services)* First Middle Last Suffix Preferred Name Birthday (MM/DD/YY) Gender SSN ___/___/___ M F Race Hispanic English Proficiency Other Language Language Proficiency Child on OHP Asian Black White Multi-Racial American Indian/ Alaska Native Hawaiian/Pac. Islander Other: _____________ Yes No None Little Moderate Proficient Little Moderate Proficient Yes No STAFF ONLY: EHS Transition Yes No CPID: Parent/Guardian 1 First Middle Last Suffix Preferred Name Birthday (MM/DD/YY) Gender SSN ___/___/___ M F Race Hispanic Relationship Status English Proficiency Other Language Language Proficiency Asian Black White Multi- Racial American Indian/ Alaska Native Hawaiian/Pac.Islander Other: _____________ Yes No Single Married Divorced Widowed None Little Moderate Proficient Little Moderate Proficient Highest Grade Completed Employment Status Child's Relationship Custody Check all that apply: Grade: 11 or less High School Grad. GED College or Adv. Training Associates Bachelors Masters Full Time Part Time Seasonal Unemployed Full Time & Training Part Time & Training Training or School Retired or Disabled Biological/Adopted/Step Grandchild Niece/Nephew Foster Other ______________ Yes No Provides Financial Support Teen Parent If teen parent, subsidized? Yes No Phone number: ( ) Cell Home Work Msg Is Adult Pregnant? May we text this number? Yes No *standard text message rates may apply* Yes No E-mail Address: Due Date: Parent/ Guardian 2 First Middle Last Suffix Preferred Name Birthday (MM/DD/YY) Gender Living in home? ___/___/___ M F Yes No Race Hispanic Relationship Status English Proficiency Other Language Language Proficiency Asian Black White Multi- Racial American Indian/ Alaska Native Hawaiian/Pac.Islander Other: ______________ Yes No Single Married Divorced Widowed None Little Moderate Proficient Little Moderate Proficient page 1