Parents, caregivers, and referring providers: Please complete as much of the form below as possible and a member of our team will contact you shortly. Have a question or need help completing the form? Give us a call at 503-675-4565!
Parent/Guardian
First Name (Required)
Last Name (Required)
Birthday (Required)
Email Address (Required)
Confirm Email Address
It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.
Mobile Phone
Opt In for Text Messages
Yes
No
Home Phone
Work Phone
Ext.
It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.
English Proficiency
Little
Moderate
None
Proficient
Other Language
American Sign Language
Amharic
Arabic
Bengali
Cantonese
Chinese
English
Farsi
Filipino
French
German
Hindi
Japanese
Mandarin
Oromo
Other
Portugese
Punjabi
Romanian
Rundi
Russian
Spanish
Swahili
Tagalog
Ukrainian
Urdu
Vietnamese
Other Language Proficiency
Little
Moderate
None
Proficient
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Address
Is your family experiencing homelessness?
Yes
No
Living Address (Required)
Address Line 2
City (Required)
State (Required)
ZIP (Required)
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to find a provider in your area.
Mailing Address same as Living Address
Mailing Address
Address Line 2
City
State
ZIP
Child (Applicant)
If you are applying for yourself or if you are referring a pregnant mother, please use the mother's information for both the adult and child's section of the application. A Family Connections Coordinator will follow up to gain more information. If you are a referring partner please leave your name, organization and contact information in the text box titled: "Is there anything else you want us to tell us about your child." Thank you.
First Name (Required)
Middle Name
Last Name (Required)
Birthday (Required)
Gender
Female
Male
Is there anything else you want to tell us about your child?
Location Preferences
Which program are you applying for? (Required)
2023-2024
Services for 2023-2024 Program Year
2024-2025
2024-2025 Program Year (Fall 2024)
Location Preference
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1st Location Preference
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2nd Location Preference
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3rd Location Preference
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- Your Address
- Available Locations
Click a location on the map to see more info
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to find a provider in your area.
Additional Applicant
Do you want to apply now for another child in your family?
Add Another Applicant
Thank you for your interest in Clackamas County Children's Commission!
Required information is missing, see above.