Parents as Teachers Enrollment Form

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Please fill out one form for each child age prenatal to kindergarten entry.

Child's First & Last Name *

School District *

Child's Date of Birth *

YYYY

Mother's Name *

Mother's Address *

Mother's Cell Phone Number *

Okay to Text *

Yes

Mother's Email Address *

Father's Name *

Father's Address

Father's Cell Phone Number

Okay to text

Yes

Clear selection

Father's Email Address

Check all that apply: *

I would like to participate in group connections.

I would like to participate in developmental screenings.

I would like to participate in personal visits.

Required

Check one *

Yes. I give permission for my child’s photo to be used in the newspaper and on Facebook.

No. I prefer my child’s photo not be used in the newspaper or on Facebook.

PARENTS AGREE TO…

✓ Be present for and participate actively in all scheduled visits.

✓ Visits in-person or virtual.

✓ Be willing to focus on your child’s development during the visits. Turn off all electronics, television or radio and engage in learning.

✓ Share what you have observed about your child since the last visit.

✓ Engage in the activity and follow up with the learning.

YOUR PARENT EDUCATOR WILL…

✓ Work together to set and reach goals for you and your family.

✓ Inform you of milestones expected at each stage of your child’s development.

✓ Help you be a good observer of your child.

✓ Collaborate to build on your strengths and skills.

✓ Personalize information to fit with your family’s needs, concerns and hopes.

CONFIDENTIALITY

By providing your consent, your individual information may be shared with THE DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION as provided by law.

The data includes information on the PAT services provided to your family, information you provided to the parent educator about your family, and information on forms you fill out as a participant in our program. For reporting purposes, your data will be summarized, limited data (this means that your name and any information that personally identifies you will not be connected to the data), may be reported to Parents as Teachers National Center (PATNC).

Parents as Teachers Missouri Curriculum Partner will not release identifiable information outside of the program without your written permission with the following exceptions:

• Our program may share information without your consent in order to protect you or others from serious harm (for example, if a family member plans to harm him or herself, if a family member plans to harm another person, or if there are concerns about abuse or neglect of a child or elderly person).

• Our program may release information if we receive a court order requiring us to do so.

Questions or concerns? You can ask your parent educator now or contact the program supervisor Amy Schnelle @ 417-693-0852.

I agree to have my information shared with DESE (Missouri Department of Education)

I do not agree to have my information shared with DESE.

For questions or more information, please contact Amy Schnelle at 417.693.0852 or aschnelle@tigersk12.org.

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