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Parents as Teachers (PAT) Enrollment Form

Required

   
The following information is kept for statistical purposes. It is kept confidential and not used to discriminate services. Please fill out the form to the best of your ability.
1. Parent 1 Namerequired
First Name
Middle (optional)
Last Name
Street Address, City, State, ZIP
5. What is your preferred communication method?requiredClick all that apply.
Click all that apply.
8. Highest Level of Education Attainedrequired
9. Employment Statusrequired
11. Marital Statusrequired
12. What is your ethnicity?*required
15. Do you qualify for free or reduced priced lunches?
17. What is the best time for a personal visit?required
The following questions are for Parent 2.
22. Does Parent 2 live at address listed above?
(mm/dd/yyyy)
xxx-xxx-xxxx
27. Highest Level of Education Attained
28. Employment Status
30. What is the second parent's ethnicity?
31. Does Parent 2 speak English?
The following are questions regarding children enrolling in the Parents as Teachers program.
32. Are you currently pregnant?required
(mm/dd/yyyy)
40. Was your child born prematurely (before 37 weeks)?required
41. Are your child's immunizations up to date?required
(mm/dd/yyyy)
43. Is your childrequired
45. Do you have other children, ages birth to 5?required
46. If yes, would you like to enroll them in Parents as Teachers?

The following questions are about additional siblings enrolling in Parents as Teachers.

(mm/dd/yyyy)
53. Was sibling born prematurely (before 37 weeks)?
54. Are sibling's immunizations up to date?
55. Is sibling