Liberty Parents as Teachers Enrollment Form 19-20
A parent educator will contact you when the 2019/2020 school year begins.
Email address *
Child's Name *
Your answer
Gender *
Child's Date of Birth *
Your answer
Family Address-please include street, city and zip code *
Your answer
Family Phone Number *
Your answer
Visit Preference *
Preferred Method of Contact *
Mother's Name (First and Last) *
Your answer
Father's Name (First and Last) *
Your answer
Guardian's Name (First and Last)
Your answer
Are There Any Other Children In The Home? If yes, please provide information regarding siblings. *
Sibling #1 Name
Your answer
Sibling #1 Birth Date
MM
/
DD
/
YYYY
Sibling #2 Name
Your answer
Sibling #2 Birth Date
MM
/
DD
/
YYYY
Sibling #3 Name
Your answer
Sibling #3 Birth Date
MM
/
DD
/
YYYY
Sibling #4 Name
Your answer
Sibling #4 Birth Date
MM
/
DD
/
YYYY
Please Indicate All Categories That Apply To Your Family
Name of Person Completing Form *
Your answer
A copy of your responses will be emailed to the address you provided.
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