P.A.T. Interest Form

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Thank you for your interest in joining the Bolivar R-1 Schools Parents As Teachers program! We are excited to meet your family and arrange a Parents As Teachers Educator to begin your monthly visits. Please give us more information about your family so we can best serve you!

Email *

Parent/Guardian First and Last name. *

How did you hear about the Bolivar R-1 Schools Parents As Teachers program? *

Phone number. *

Select the preferred avenue of contact. *

The email address provided.

Phone call to the number provided.

Text message to the number provided.

Please provide your address. *

Please list the names of the children living in the home and their birthdays. *

Do you have any developmental concerns with our child/children at this time? *

What is the best day of the week and time of day for a Parent Educator to do home visits or visits at Early Childhood Learning Center with your family? *

If our annual caseload for families is full, would your family like to be added to our waitlist? *

Yes, please add my family to your waitlist!

No. I would like to have a yearly Developmental Screening conducted with my child/children.

No, I would not like to be added to the waitlist.

Send me a copy of my responses.

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