Albina Head Start & Early Head Start Request for more information
Thank you for your interest in Albina Head Start & Early Head Start.
Please fill out the following form and a member of our social services staff will contact you ASAP. Our goal is to contact you within 2 business days (M-F). If you have not received a response within that time please contact the EHS Main Office.
THIS IS NOT AN APPLICATION FOR ENROLLMENT
IF REQUESTING INFORMATION ABOUT AN APPLICATION THAT HAS ALREADY BEEN SUBMITTED PLEASE CALL:
HEAD STAR
EARLY HEAD START (503) 236-9389
Please note: Albina Head Start and Early Head Start have multiple locations in North, North East and South East Portland.
Albina provides services to families currently living in the Portland Public School District within the North, North East (not past NE 110th) and South East (not past SE 110th) areas of Portland.
If you are not in our service area please visit
https://eclkc.ohs.acf.hhs.gov/hslc/HeadStartOffices
to find a Head Start near you!
* Required
Parent/Guardian First and Last Name:
*
Your answer
Living Address:
*
Your answer
Phone Number:
*
Your answer
E-mail Address:
*
Your answer
Best Times to Contact: between 10am -12pm
Between 8am-10am
Between 10am-12pm
Between 12pm-2pm
Between 2pm-4pm
Between 4pm-5:30pm
Any Time Between 8am-5:30pm
Other:
Birth Date of Child #1 :
*
IF PRENATAL USE MOTHERS BIRTHDAY OR DUE DATE
MM
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DD
/
YYYY
Birth Date of Child #2
MM
/
DD
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YYYY
Programs Interested in: Center based services
CHECK ALL THAT APPLY
Center Based Services
Home Based Services
Prenatal Home Base Services
Unsure
Type of information/follow up requested: email, phone call
*
CHECK ALL THAT APPLY
Phone Call
E-mail
An application mailed to the address provided
Other:
Required
How did you hear about Albina Head Start? WIC
*
CHECK ALL THAT APPLY
Facebook
Craigslist
Albina's Website
Word of Mouth
PDXChildCare.com
WIC
Other:
Required
Questions or any other specific information requested:
Your answer
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