Please provide the following information to request contact by OCDC
This interest form is not a complete application for services. One of our Enrollment Specialists will reach out within 3 business days to give you more information about our programs & complete an application.
Your location
CITY WHERE SERVICES ARE NEEDED
*
COUNTY (IF KNOWN)
Select County/Seleccione el Condado
Clackamas
Hood River
Jackson
Jefferson
Josephine
Klamath
Malheur
Marion
Morrow
Multnomah
Polk
South Marion
Umatilla
Wasco
Washington
Yamhill
Other
OCDC SITE LOCATION (IF KNOWN)
Your contact information
PARENT/GUARDIAN NAME
*
PREFERRED LANGUAGE
English
Spanish
Other
PHONE NUMBER
*
MAY WE TEXT THIS NUMBER?
*
Please Select/Por favor selecciona
No
Yes/Si
BEST TIME OF DAY TO REACH YOU
*
Please Select
Morning
Afternoon
Evening
Any
HOME ADDRESS
EMAIL ADDRESS
WOULD YOU LIKE AN EMAIL CONFIRMATION?
*
Please Select/Por favor selecciona
No
Yes/Si
Your family information
IS ANYONE IN THE FAMILY HOUSEHOLD PREGNANT?
*
Please Select/Por favor selecciona
No
Yes/Si
AT LEAST ONE FAMILY MEMBER IS WORKING IN AGRICULTURE
*
Please Select/Por favor selecciona
No
Yes/Si
DOES THE FAMILY RECEIVE PUBLIC BENEFITS?
TANF
SSI
SNAP/Food Stamps
Children who need services
Please add information about all your kids under the age of 5 that need our services. To Add information about child push 'Add Child' button
CHILD'S NAME
*
CHILD'S DATE OF BIRTH
*
ARE THERE ANY CONCERNS REGARDING YOUR CHILD'S EDUCATION?
*
Please Select/Por favor selecciona
No
Yes/Si
If you need any further assistance please contact your nearest
OCDC location