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Parents As Teachers Enrollment Form
Please complete if you would like to participate in the Parents As Teachers Program
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* Indicates required question
Email
*
Your email
Child's Name
*
Last, First Middle
Your answer
Child's Age
*
Your answer
Child's Gender
*
Boy
Girl
Child's Date of Birth
*
month/day/year
Your answer
Child's Birth Place
*
city, state, country
Your answer
Multiple Birth Order
for twins, triplets, etc....
Your answer
Is this Child Hispanic/Latino Ethnicity?
*
Cuban, Mexican, Puerto Rican, South or Central America or other Spanish culture/origin
Yes
No
Child's Race
*
If one or more, please rank as primary or secondary
American Indian or Alaskan
African American/Black
Asian
Native Hawaiian/Pacific Islander
White
Required
Home Address
*
Your answer
City
*
Choose
Grand Blanc
Holly
Flint
Burton
Zip Code
*
Your answer
Primary Contact Phone Number
*
Your answer
Primary Caregiver Name
*
Your answer
Best day of the week and time frame to schedule an orientation visit
*
visit times are available Monday-Friday from 8 am - 4 pm, ex. Mondays 10 am -1 pm
Your answer
Emergency Contact Name
*
Your answer
Emergency Contact Phone Number
*
Your answer
With Whom Does This Child Live?
*
Choose
Both Parents
Father Only
Mother Only
Legal Guardian
Physical Custody
Foster Care
Other
Mother/Stepdad
Father/Stepmom
Blended Family
Child Living on Own
Joint Custody
Parents Marital Status
*
Choose
Married
Not married, living together
Single parents, shared custody
Single parent, no shared time
Mother's Name
*
first and last
Your answer
Mother's Date of Birth
*
month/day/year
Your answer
Mother Active Military?
*
yes
no
Mother's country of birth
*
Your answer
Mother's Date of Naturalization
Your answer
Mother's Education Completed
*
Your answer
Mother's Place of Employment/Title
*
Your answer
Mother's Cell Phone
*
Your answer
Mother's Work Phone
Your answer
Father's Name
*
first and last
Your answer
Father's Date of Birth
*
month/day/year
Your answer
Father Active Military?
*
yes
no
Father's country of birth
*
Your answer
Father's Date of Naturalization
Your answer
Father's Education Completed
*
Your answer
Father's Cell Phone
*
Your answer
Father's Work Phone
Your answer
Father's Place of Employment/Title
*
Your answer
Internet Access At Home?
*
Yes
No
Preferred Email Address
*
Your answer
Other Children in the Family
*
Name, Birthdate, Gender
Your answer
Has Your Child Received Special Education Services
*
Currently
Previously
No
Has Your Child Received Any of the Following Services?
*
Speech Therapy
Head Start
Early On
Other:
Required
Child's First Language
*
Your answer
Language Spoken in the Home
*
Your answer
Send me a copy of my responses.
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