Parents As Teachers Enrollment Form
Please include all of the required information.  Only enroll children who have not started kindergarten.

Once your enrollment form is received your family will be assigned a parent educator who will contact you to arrange a visit.
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Email *
How did you hear about the Smithville Parents As Teachers program? *
Times I'm available for PAT appointments *
Required
Days I'm available *
Required
Mother's or Guardian's Name (First & Last) *
Mother's Ethnicity *
Father's  or Guardian's  Name (First & Last) *
Father's  or Guardian's  Race
 *
Parents' Marital Status *
Address *
Phone *
Child #1 Full Name: Include First, Middle, & Last Name *
Child#1 Date of Birth *
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Child #1 Ethnicity *
Child #2 Full Name: Include First, Middle, & Last Name
Child #2 Date of Birth
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/
DD
/
YYYY
Child #2 Ethnicity *
Child #3 Full Name: Include First, Middle, & Last Name
Child #3 Date of Birth
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/
DD
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YYYY
Child #3 Ethnicity *
Child #4 Full Name: Include First, Middle, & Last Name
Child #4 Date of Birth
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DD
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YYYY
Child #4 Ethnicity *
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