Parents as Teachers Enrollment Form
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*
Required
Parent #1
Parent #1 Name
*
required
First Name
Last Name
Parent #1 Email Address
Provide prefered contact email
Parent #1 Address
Include City and Zip
Parent #1 Phone Number
Provide prefered contact number
Parent #1 Date of Birth
Must contain a date in MM/DD/YYYY format
Parent #1 Marital Status
Married
Single
Partnered
Parent #1 Employment Status
Full Time
Part Time
Unemployed
Parent #1 Highest Education Obtained
High School
Some College
College Degree
Other
Parent #1 Ethnicity
Hispanic/Latino
Not Hispanic/Latino
Parent #1 Race
American Indian or Alaskan Native
Black or African American
Asian
Native Hawaiian or other Pacific Islander
White
Parent #2
Parent #2 Name
First Name
Last Name
Parent #2 Address
Include City and Zip
Parent #2 Phone Number
Provide prefered contact number
Parent #2 Date of Birth
Must contain a date in MM/DD/YYYY format
Parent #2 Marital Status
Married
Single
Partnered
Parent #2 Employment Status
Full Time
Part Time
Unemployed
Parent #2 Highest Education Obtained
High School
Some College
College Degree
Other
Parent #2 Ethnicity
Hispanic/Latino
Not Hispanic/Latino
Parent #2 Race
American Indian or Alaskan Native
Black or African American
Asian
Native Hawaiian or other Pacific Islander
White
Is either parent a first time parents of a child under 3 years?
Yes
No
Primary Language Spoken in Home
What is the family income?
Please select the total family income per year.
Less than $25,000
$25,000 tp $34,999
$35,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
$100,000 to $149,999
$150,000 to $199,999
$200,000 or more
Please select the total family income per year.
Child #1
Child #1
*
required
Full Legal Name
First Name
Nickname (optional)
Middle (optional)
Last Name
Full Legal Name
Child #1 Date of Birth
Must contain a date in MM/DD/YYYY format
Child #1 Gender
Male
Female
Unknown
Child #1 Birth Weight
Child #1 Due Date
Must contain a date in MM/DD/YYYY format
Child #1 Ethnicity
Hispanic/Latino
Not Hispanic/Latino
Child #1 Race
American Indian or Alaskan Native
Black or African American
Asian
Native Hawaiian or other Pacific Islander
White
Multi-Racial
European-American
Unknown
Child #1 Are Immunizations up to date at enrollment
Yes
No
Child #1 Do you have any concerns about development
Yes
No
If yes, please explain:
Child #2
Child #2
Full Legal Name
First Name
Nickname
Middle
Last Name
Full Legal Name
Child #2 Date of Birth
Must contain a date in MM/DD/YYYY format
Child #2 Gender
Male
Female
Unknown
Child #2 Birth Weight
Child #2 Due Date
Must contain a date in MM/DD/YYYY format
Child #2 Ethnicity
Hispanic/Latino
Not Hispanic/Latino
Child #2 Race
American Indian or Alaskan Native
Black or African American
Asian
Native Hawaiian or other Pacific Islander
White
Multi-Racial
European-American
Unknown
Child #2 Are Immunizations up to date at enrollment
Yes
No
Child #2 Do you have any concerns about development
Yes
No
How did you hear about Parents as Teachers?
Please list other siblings over 5 years and their ages.
Other information and comments
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