Parents as Teachers Enrollment Form
We are excited to enroll your family into Parents as Teachers! Please fill out the following questions to enroll and determine level of services. All families receive an annual screening which includes health, hearing, vision and development. You will also be emailed schedules for play groups and informational meetings.
Last name of Parent 1: *
First name of Parent 1: *
Race of Parent 1 *
Parent 1 Non-Hispanic/Latino *
Last Name of Parent 2: *
First name of Parent 2: *
Race of Parent 2 *
Parent 2 Non-Hispanic/Latino *
Marital Status of Parents *
Times available for a visit *
Primary Street Address *
City *
Zip Code *
Phone Number (mom or guardian) *
Text messages available at this number? *
Phone Number (dad or guardian)
Text messages available at this number? *
Email Address *
Email Address
Do both parents live in the home? *
Is either parent 19 years old or younger? *
Did both parents complete high school or receive a GED? *
Does either parent have a disability or chronic health condition? *
Is either parent deployed or within 2 years of returning from a deployment? *
Primary language spoken in the home? *
Is either parent foreign born and have entered the country within the past 5 years? *
Does anyone in the household receive WIC or Medicaid? *
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