ACCESS Application

Adult Name(s) (Membership includes 2 adults in same household)*
Mailing Address:*
City:*
County:*
State*
Zip Code:*
Email Address:*
Phone:*
Please List Child(ren) Name(s) and Birthdate(s). Your membership includes 2 named adults, and up to 4 children.*
Gilbert House ACCESS Memberships are made possible through grant funding and the generous support of donors. To ensure continued funding for this vital community program, please complete the following sections as part of a CONFIDENTIAL required survey. We value your privacy and will keep this personal information separate from your membership. The answers to the following questions are used to determine eligibility for our ACCESS program; they are also used for statistical purposes and communicating with our donors.
- I understand these terms.
Zip Code:*
Total number of children in your household:*
Please list the ages of each of your children:*
What is your total annual household income, before taxes?*
How did you hear about the ACCESS Membership?*
Are you Mexican, Mexican-American, Chicano, Puerto Rican, Cuban, Cuban-American, or some other Spanish, Hispanic, or Latino group?
Are you White, Black or African-American, American Indian or Alaskan Native, Asian, Native Hawaiian, or other Pacific Islander, or some other race (please specify)?
Why is a Gilbert House Membership important to your family?*
Is there Anything else you would like us to know as we consider your family for an ACCESS Membership?*
When accepted for membership, you will receive instructions on downloading your e-membership card on your phone. If you need a physical membership card, there will be an additional $5 charge.*
- I understand, and will be able to download the membership app
- I will need to pay $5 for a physical membership card
Please upload a copy of one of the following eligibility or coverage notification letters with current dates. The letter must include the name and address of at least one family member and be dated within the past six months. Choose one of the following: Section 8/Public Housing; Children's Health Insurance Plan (CHIP), Medicaid, Oregon Health Plan; Free and reduced school Lunch, Food Stamps, WIC documentation; Temporary Assistance for Needy Families (TANF); Big Brothers Big Sisters of America; Head Start Preschool Program; Unemployment.*
Please allow 2-3 weeks for application processing. Our review will include consideration of family size, annual income, residence address, and your assistance documentation to determine if you are a candidate for our program. You will receive an email/letter either awarding or denying ACCESS membership. If you are awarded a membership, you must bring the printed confirmation letter and your $60 payment to the Museum to activate your membership. The confirmation letter will be valid for two months.
- I understand these terms.

ACCESS Application

ACCESS Application

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