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Financial Assistance Application

for

Child Name

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Please select the childcare center for which you are requesting financial assistance.
Do you or your child live, work, or play in Yamhill County?

Please fill in the details about the child that will, or would be, receiving childcare.

Additional children in the home seeking financial assistance for care will be completed separately
First Name *
Last Name *
Date of Birth *
Age at time of application
Preferred Language *

Does your child have a diagnosed disability?

Is the child in foster care or in DHS custody?

Is the child on an Individualized Family Service Plan (IFSP)?

Does the child have a physical or mental health condition?

Please fill in the details about the child's PRIMARY parent or guardian ("Parent #1")

Select the Parent #1's relationship to the child

Please select the Parent #1's employer
Does Parent # 1 work full time or part time?
Full time(32+ hours / week)
‍Part time (less than 32 hours / week)
Does the child live in household with Parent # 1?
Select yes if child lives with parent/guardian half-time (50%) or more in the same household.

Please complete the following 3 questions about the child's home and living situation in Parent #1's household

Household Type
Select One
** Does not have to be biological parents to determine number of parental figures in each household child resides in.
Total number of individuals living in Parent # 1 household
Please include all adults and children that live in the home part-time or more.
Total Household Members *
Parent #1 Household Status
Select One
Living with friend or family
Couch surfing or staying at different houses
Shelter or transitional housing or homelessness
Renting
Own Home
Would you like to add a parent or guardian who lives in a separate household?
If there is a second Parent or Guardian (Parent # 2) who the child lives with in a separate household, please fill the following questions.

If the child does not live with a Parent # 2, ignore the following questions and click next to move forward.

Please fill in the details about the child's ADDITIONAL parent or guardian
("Parent #2")

Select the Parent #2's relationship to the child

Please select the Parent #2's employer
Does Parent #2 work full time or part time?
Full time(32+ hours / week)
‍Part time (less than 32 hours / week)
Does the child live in household with
Parent # 2?
Select yes if child lives with parent/guardian half-time (50%) or more in the same household.

Please complete the following 3 questions about the child's home and living situation in
Parent #2's household

Household Type
Select One
** Does not have to be biological parents to determine number of parental figures in each household child resides in.
Total number of individuals living in Parent # 2's household
Please include all adults and children that live in the home part-time or more.
Parent #2 Household Status
Select One
Living with friend or family
Couch surfing or staying at different houses
Shelter or transitional housing or homelessness
Renting
Own Home
The following questions about the child and family are confidential. The answers are used to understand each child and their family's unique set of needs.

The following questions are required to determine eligibility for scholarship dispersement.
Click "next" to continue.
Select any benefits being received by by someone living in any of the child's households...
Is any member of the child's household(s)...
Currently pregnant or expecting a child?
Is the child or any member of the child's household(s)...
In (or has been in) the custody of DHS or foster care?
Is any member of the child's household(s)...
Working (or has worked) in agriculture or on farms?
Does the child have...
Parents that are separated or divorced?
Has any member of the child's household(s)...
Currently using or in recovery (past or present) from alcohol or other drugs/substances?
Is the child or any member of the child's household(s)...
Depressed or mentally ill (or has been)?
Has any member of the child's household(s)...
Been incarcerated or in jail for an extended period of time?
Has the child or any member of the child's household(s)...
Experienced domestic violence, inappropriate touching, stalking, or sexual assault?
Does the child or any member of the child's household(s)...
Identify as medically fragile or has / had a disabling condition?
Is any member of the child's household(s)...
Currently attend school or trade training program?
Has any member of the child's household(s)...
Not graduated from high school or never obtained a GED
(adult household members only)
Has the child or any member of the child's household(s)...
Experienced, or is concerned about experiencing, physical or emotional harm?
Has the child or any member of the child's household(s)...
Felt or feel they had to wear dirty clothes and/or didn't or doesn't feel cared for?
Has the child or any member of the child's household(s)...
Ever felt or feel they didn't or don't have enough to eat?
Been raised by a single parent, teen or young parent?
Would you like someone to contact you and talk about supports and services for:
  • Housing & Shelter
  • Food
  • Clothing
  • Depression or Anxiety
  • Parent Support
  • Alcohol or Drug Support
  • School & Education Support
  • Legal Help
  • Employment & Job Seeking Help
  • Behavioral Health
  • Medical Care
  • Pregnancy Care
  • Other
Review
Please verify that the information that you have provided below are correct before submitting
Review Application

Childcare facility

Name of Childcare facility for which you are applying for assistance
N.A.

Child Details

Does the child live, work play in Yamhill?
N.A.
First Name
N.A.
Last Name
N.A.
Date of Birth
N.A.
Age
N.A.
Preferred Language
N.A.
Diagnosed Disability?
N.A.
Foster Care or DHS?
N.A.
Individualized Family Service Plan (IFSP)?
N.A.
Physical or Mental Health Condition?
N.A.

Parent/Guardian # 1

First name
N.A.
Last Name
N.A.
Email
N.A.
Phone Number
N.A.
Relationship to Child
N.A.
Employer Name
N.A.
Employer Name - Other
N.A.
Employment Status
N.A.
Lives with Child?
N.A.
Household Type
N.A.
Number of People in this Household
N.A.

Parent/Guardian # 2

First name
N.A.
Last Name
N.A.
Email
N.A.
Phone Number
N.A.
Relationship to Child
N.A.
Employer Name
N.A.
Employer Name - Other
N.A.
Employment Status
N.A.
Lives with Child?
N.A.
Household Type
N.A.
Number of People in this Household
N.A.

Family & Child

Is anyone in the household pregnant?
N.A.
Has anyone in the household been in custody of DHS?
N.A.
Does anyone in the household work in agriculture or farms?
N.A.
Are the child's parents separated or divorced?
N.A.
Has any member of the household been in recovery from alcohol or other substances?
N.A.
Has any member of the household been depressed or mentally ill?
N.A.
Has any member of the household been incarcerated or in jail for an extended period of time?
N.A.
Has any member of the household experienced domestic violence, inappropriate touching, or sexual assault?
N.A.
Does any member of the household identify as medically fragile or has a disabling condition?
N.A.
Is any member of the household currently attending school or trade training program?
N.A.
Has any adult in the household never graducated highschool or received a GED?
N.A.
Has any member of the household experienced, or is concerned about experiencing, physical or emotional harm?
N.A.
Has any member of the household felt that they had to wear dirty clothes?
N.A.
Has any member of the household felt they didn't have enough to eat?
N.A.
Has the child been raised by a single parent, teen or young parent?
N.A.
Would you like someone to contact you and talk about support and service?
N.A.
Submit
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Need help?
email us at admin@oasisyamhill.org,

or

call Little Bird Childcare: (503) 714-1055
call Mi Escuelita: (503) 537-2112

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