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2023 Alder Montessori Lottery Interest Form

Alder Montessori Preschool is funded by the State of Oregon Preschool Promise Program and Multnomah County's Preschool For All. Families must meet income and age eligibility requirements, and preferred enrollment is given to families in the Alder Elementary school catchment area. Most new students will be 3 at entry into our program. Alder Montessori is free of charge and follows the Alder Elementary school day calendar.

Email(Required)

** Please answer all sections on this form as thoroughly as possible. Incomplete or incorrect responses may impact your child's enrollment decision **

Eligibility

Use this section to determine if your family is eligible to enroll your 3 or 4 year-old child in Alder Montessori.

WHAT DO WE MEAN BY ELIGIBLE?

Alder Montessori is funded by the State of Oregon Preschool Promise Program and Multnomah County Preschool For All, so our students must meet their income and age requirements.

We also partner with Reynolds School District and are co-located in Alder Elementary school to help meet community needs, so we give priority to students living within the Alder Elementary catchment area.

What age will your child be on September 1, 2023?(Required)

3 years old

4 years old

Other

Is your annual family income at or below this level?(Required)

Yes

Other

Does your family live in the Alder Elementary catchment area?(Required)

Please click the link and enter your home address into the search bar above the map: https://www.greatschools.org/school-district-boundaries-map/

Yes

If 'No', which elementary school neighborhood do you live in?

IF YOU ANSWERED NO to one or more of the questions in this section, and you are not completing this application for a foster child or experiencing homelessness, you MAY not be eligible for Alder Montessori.

Student Information

Student Name(Required)

Student Date of Birth(Required)

MM slash DD slash YYYY

Student Gender(Required)

Male

Female

Other

What is/are your child's home language(s)? Select all that apply:(Required)

Spanish

English

Karen

Karenni

Burmese

Russian

Swahili

Other

Student Home Address(Required)

How do you identify your child’s race or ethnicity?(Required)

Does your family have an Individual Family Service Plan (IFSP) to support your child's development?(Required)

Yes

What supports does your child's IFSP provide?(Required)

Medical Information

Does your child have any health, nutrition, or behavioral concerns that requires specialized supports?(Required)

Yes

Please describe concerns and list any health partners or other providers you would like us to know about:(Required)

Parent / Guardian Information

Parent / Guardian Name(Required)

Relationship to child(Required)

Parent

Legal Guardian

Foster Parent

Other

Parent / Guardian Phone Number(Required)

Parent / Guardian Home Address (if different than Student Address)

How do you prefer to be contacted?(Required)

Phone Call

Phone text

Other

In what language do you prefer to be contacted?

Spanish

English

Karen

Karenni

Burmese

Russian

Swahili

Other

Household Information

What is your household size?(Required)

To calculate add the TOTAL NUMBER OF ADULTS + TOTAL NUMBER OF DEPENDENTS =

Please enter a number greater than or equal to 1.

Total annual income (most recent tax year or past 12 months):

Please be as accurate as possible. Income will be verified for wages, child support, unemployment, cash grants, TANF and SSI upon enrollment, and may impact your child's eligibility.

** If you do not know your annual income, use your monthly income and write 'Monthly'

Siblings who attend Alder Elementary or Alder Montessori

Please mark any that apply to your household (optional):

What we do with this information: Alder Montessori prioritizes enrollment for students and families experiencing the greatest barriers to accessing high quality early learning. We do not discriminate, stigmatize, or ask for details other than those we may need to better serve our students. Information will not be shared with outside agencies or individuals without your consent. ** This section is optional, though leaving out this information may impact the priority of your enrollment. **

Difficulty meeting transportation needs

Help with food sources through programs like Oregon Food Bank and/or SNAP

Temporary Assistance for Needy Families (TANF)

Women, Infants, and Children Program (WIC)

Medicaid/Oregon Health Plan (OHP)

Child is living in a foster home, or with adults other than parents

You consider your family to be homeless

A parent is, or has been, incarcerated

Single-parent household (meaning headed by a parent/guardian who is widowed, divorced, or otherwise unpartnered)

None of the above

Other

What are your reasons for seeking an early learning program for your child? (Select ALL that apply)

want my child to interact with more children their own age

I want my child to begin building academic skills like math and literacy

I need my child to be in a full-time program so that I (or someone in my family) can work

The program my child currently attends is too expensive for my family

I am not happy with the program my child currently attends

I want my child to become more fluent in English before they begin Elementary school

Other

You indicated "other" for your reasons for seeking an early learning program for your child. Please explain:

Is there any other information you would like us to know about your family or your child?

Agreement & Signature

AUTHORIZATION TO USE AND/OR RELEASE OF PERSONAL INFORMATION By selecting 'Yes' following this statement, I understand and agree that the information on this Alder Montessori School form is correct and may be shared with entities and individuals involved in the Preschool Promise Program, Reynolds School District, and Early Learning Multnomah for the purpose of coordinating student enrollment.

Select 'Yes' below to allow Alder Montessori to share enrollment information from this form with Preschool Promise, Early Learning Multnomah, Reynolds School District registration officers, and program staff.(Required)

Yes

PLEASE READ CAREFULLY AND TYPE YOUR NAME BELOW

By signing this form, I am answering all information as accurately as I currently know it.

I am applying for enrollment in the Alder Montessori program, a no-cost preschool and kindergarten program inside Alder Elementary School. I understand that enrollment in this program is based on eligibility and is determined by lottery. If my child is offered enrollment in Alder Montessori, I understand that:

I must provide verification of eligibility (Age of child, residence, income).
I must complete and turn in all required paperwork for Alder Montessori, Preschool Promise and Reynolds School District. I can ask for help from program staff.
My child will attend school five days a week (unless my child is ill, family is away, or the school is closed).
This is a multi-year program, and our goal is for each student to remain in our school for 2 full years.
I/We as parents will attend conferences and parent education nights, and be as involved and engaged as is possible.

Type your legal name to sign this form:(Required)

No student, employee, or applicant for employment at Alder Montessori shall, on the basis of race, color, gender, age, sexual orientation, religion, national origin, marital status, or disability, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any employment or educational program or activity.