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 START
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!
Sign in to Google to save your progress. Learn more
Parent/Guardian First and Last Name: *
Living Address: *
Phone Number: *
E-mail Address: *
Best Times to Contact: between 10am -12pm
Birth Date of Child #1 : *
IF PRENATAL USE MOTHERS BIRTHDAY OR DUE DATE
MM
/
DD
/
YYYY
Birth Date of Child #2
MM
/
DD
/
YYYY
Programs Interested in:  Center based services
CHECK ALL THAT APPLY
Type of information/follow up requested: email, phone call *
CHECK ALL THAT APPLY
Required
How did you hear about Albina Head Start? WIC *
CHECK ALL THAT APPLY
Required
Questions or any other specific information requested:
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms