Enrollment Refer a Family or Enroll Today! Thank you for your interest in our program! Please complete this form with as much information as possible. We will be contacting you shortly! Have questions? Give us a call at (503) 675-4565. Child Information Child's Name Child's Birthdate Child's GenderPlease select... Male Female Other Who Is Taking Care Of This ChildPlease select... Parent Grandparent Aunt/Uncle Foster Parent Friend Other Please Specify Message Parent Information Parent/Guardian Name Parent/Guardian Phone Parent/Guardian Date of Birth Parent/Guardian Language Parent/Guardian Address Parent/Guardian City Parent/Guardian StatePlease select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau Parent/Guardian Zipcode Referral Referred By:Please select... Mother Father Grandparent Foster Parent School Hospital Agency Other Please Specify Referral Name Referral Phone Referral Email Captcha Please enter the characters you see in this picture: Characters This helps prevent automated form submissions. If you are not sure what the characters are, make your best guess. You will have another try in the next screen.Can't see the image? Click here for an audible version in English. Need assistance with this form?