Parents As Teachers Enrollment Form
Please complete if you would like to participate in the Parents As Teachers Program
Email address *
Child's Name *
Last, First Middle
Your answer
Child's Age *
Your answer
Child's Gender *
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
Child's Race *
If one or more, please rank as primary or secondary
Required
Home Address *
Your answer
City *
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? *
Parents Marital Status *
Mother's Name *
first and last
Your answer
Mother's Date of Birth *
month/day/year
Your answer
Mother Active Military? *
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? *
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? *
Preferred Email Address *
Your answer
Other Children in the Family *
Name, Birthdate, Gender
Your answer
Has Your Child Received Special Education Services *
Has Your Child Received Any of the Following Services? *
Required
Child's First Language *
Your answer
Language Spoken in the Home *
Your answer
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