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Francis Howell School District Parents as Teachers Enrollment
Parents as Teachers is a FREE program for families with children (prenatal until Kindergarten entry).
If you have any questions or concerns, please call our office at 636-851-6060
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* Indicates required question
Email
*
Your email
Person filling out this form is:
*
Parent/Guardian
PAT Staff
Other:
1st Guardian's First Name
*
Your answer
1st Guardian's Last Name
*
Your answer
1st Guardian's work status
*
Full time
Part time
Currently not working
Comments concerning availability for visits
Your answer
1st Guardian's relationship to child
*
Mother
Father
Stepmother
Stepfather
Grandparent
Foster Parent
Guardian
Other
Required
1st Guardian's Street Address
*
Your answer
1st Guardian's City
*
Your answer
1st Guardian's Zip Code
*
Your answer
1st Guardian's Phone Number
*
Your answer
1st Guardian's Preferred Method of Contact
*
Phone Call
Text
E-mail
Required
1st Guardian's Ethnicity (click all that apply)
*
Hispanic/Latino
American Indian or Alaskan Native
Asian
Black or African American
Multi race
Native Hawaiian
Other Pacific Islander
White
Prefer not to report
Other
Required
Primary Language Spoken in the Home (more than 50%)
*
Your answer
Adult(s) the child(ren) lives with? (click all that apply)
*
Mother
Father
Both Parents
Guardian
Grandparent(s)
Foster Parent
Joint Custody
Placed by DMH
Required
2nd Guardian's First Name
Your answer
2nd Guardian's Last Name
Your answer
2nd Guardian's work status
Full time
Part time
Currently not working
Clear selection
Comments concerning availability for visits
Your answer
2nd Guardian's relationship to child
Mother
Father
Stepmother
Stepfather
Grandparent
Foster Parent
Guardian
2nd Guardian's Email Address
Your answer
2nd Guardian's Phone Number
Your answer
2nd Guardian's Preferred Method of Contact
Phone Call
Text
E-mail
2nd Guardian's Ethnicity (click all that apply)
Hispanic/Latino
American Indian or Alaskan Native
Asian
Black or African American
Multi race
Native Hawaiian
Other Pacific Islander
White
Prefer not to report
Other
Check
ALL
days/times that you are available for visits. V
isits outside of 8 am to 4 pm are limited and may impact our ability to serve your family consistently during the program year.
This may also impact how soon we can schedule visits with your family.
*
Before 8 am
8am to 2pm
2pm to 4 pm
After 4 pm
Monday
Tuesday
Wednesday
Thursday
Friday
Before 8 am
8am to 2pm
2pm to 4 pm
After 4 pm
Monday
Tuesday
Wednesday
Thursday
Friday
1st Child's Legal Name (First)
*
Your answer
1st Child's Legal Name (Middle)
Your answer
1st Child's Legal Name (Last)
*
Your answer
1st Child's Ethnicity (click all that apply)
*
Hispanic/Latino
American Indian or Alaskan Native
Asian
Black or African American
Multi race
Native Hawaiian
Other Pacific Islander
White
Prefer not to report
Other
Required
1st Child's Birth Date
*
MM
/
DD
/
YYYY
1st Child's Gender
*
Female
Male
2nd Child's Legal Name (First)
Your answer
2nd Child's Legal Name (Middle)
Your answer
2nd Child's Legal Name (Last)
Your answer
2nd Child's Ethnicity (click all that apply)
Hispanic/Latino
American Indian or Alaskan Native
Asian
Black or African American
Multi race
Native Hawaiian
Other Pacific Islander
White
Prefer not to report
Other
2nd Child's Birth Date
MM
/
DD
/
YYYY
2nd Child's Gender
Female
Male
Clear selection
3rd Child's Legal Name (First)
Your answer
3rd Child's Legal Name (Middle)
Your answer
3rd Child's Legal Name (Last)
Your answer
3rd Child's Ethnicity (click all that apply)
Hispanic/Latino
American Indian or Alaskan Native
Asian
Black or African American
Multi race
Native Hawaiian
Other Pacific Islander
White
Prefer not to report
Other
3rd Child's Birth Date
MM
/
DD
/
YYYY
3rd Child's Gender
Female
Male
Clear selection
Do you have any specific area of need or concern?
Your answer
Does your family receive supports from Social Service Agencies?
*
Yes
No
Prefer not to report
If your family does receive supports from Social Service Agencies, please tell us which agencies.
Your answer
What is your last year of school completed?
*
Did not complete High School or receive GED
High School or passed equivalency exam
Some college or up to Associate's Degree
Bachelor's Degree
Master's or beyond
Prefer not to report
Where did you learn about our programming?
Childcare/Daycare
Crisis Nursery/WIC/Division of Family Services
Doctor/NICU/Hospital
Family/Friends/Neighbors/Coworkers
FHSD Preschool
FHSD Website
First Steps
Head Start
PALS
Parents as Teachers flyer
Parents as Teachers sign
PAT Family Education Center/DIAL Screening
Social Media
Other:
Clear selection
Have you ever participated in Parents as Teachers before?
*
Yes
No
If yes, where did you participate in PAT?
Your answer
Comments:
Your answer
A copy of your responses will be emailed to the address you provided.
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