Liberty Parents as Teachers Enrollment Form 20-21
Thank you for your interest in the Liberty Parents As Teachers program. A parent educator will be in contact to follow-up on your enrollment upon their return for the 2020-21 school year on August 24 or shortly after. Thank you!
Email address *
Child's Last & First Name *
Gender *
Child's Date of Birth *
Family Street Address, City and Zip Code *
Family Phone Number include area code *
Visit Preference *
Preferred Method of Contact *
Mother's Name (First and Last) *
Father's Name (First and Last) *
Guardian's Name (First and Last)
Are There Any Other Children In The Home? If yes, please provide information regarding siblings. *
Sibling #1 First and Last Name
Sibling #1 Birth Date
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DD
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YYYY
Sibling #2 First and Last Name
Sibling #2 Birth Date
MM
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DD
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YYYY
Sibling #3 First and Last Name
Sibling #3 Birth Date
MM
/
DD
/
YYYY
Sibling #4 First and Last Name
Sibling #4 Birth Date
MM
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DD
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YYYY
Please Indicate All Categories That Apply To Your Family
Name of Person Completing Form *
A copy of your responses will be emailed to the address you provided.
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