Editing previous response:

Please fix the highlighted areas below before submitting.

Parents as Teachers Information and Enrollment Form

Please complete the form below. Required fields marked with an asterisk *

PARENT/GUARDIAN 1 INFORMATION

Parent/Guardian 1 - First Name*

Answer required for "Parent/Guardian 1 - First Name"

Parent/Guardian 1 - Last Name*

Answer required for "Parent/Guardian 1 - Last Name"

Gender*

Answer required for "Gender"

Female

Male

Prefer Not to Report

Date of Birth*

Answer required for "Date of Birth"

Street Address*

Answer required for "Street Address"

City*

Answer required for "City"

State*

Answer required for "State"

Zip/Postal*

Answer required for "Zip/Postal"

Phone Number*

Number Required

Email Address

Answer required for "Email Address"

Ethnicity*

Answer required for "Ethnicity"

Hispanic/Latino

Non-Hispanic/Latino

Race*

Answer required for "Race"

American Indian or Alaskan Native

Asian

Black or African American

Caucasian or White

Native Hawaiian

Prefer Not to Report

Other:

English Speaking?*

Answer required for "English Speaking?"

Yes

Primary Language*

Answer required for "Primary Language"

Marital Status*

Answer required for "Marital Status"

Relationship to Child*

Answer required for "Relationship to Child"

Highest Level of Education Completed

Answer required for "Highest Level of Education Completed"

Currently Enrolled In

Answer required for "Currently Enrolled In"

Current Employment

Answer required for "Current Employment"

Full Time

Part Time

Not Employeed

Current Housing

Answer required for "Current Housing"

Health Insurance

Answer required for "Health Insurance"

Dental Insurance

Answer required for "Dental Insurance"

Military Status (Select all that Apply)

Answer required for "Military Status (Select all that Apply)"

Active Duty

Reserves/National Guard

Non Applicable - Not in Military

Planning for Deployment

Returned from Deployment within the past 2 years

Reasons for Enrolling - What are you hoping to get out of the program? (select all that apply)

Answer required for "Reasons for Enrolling - What are you hoping to get out of the program? (select all that apply)"

Learn about Child Development and Parenting

Support for Educational Attainment and/or Employment

Support/Information on Family Planning

Support for Maternal Health and Well-Being

Increase Social Support

Support for Obtaining Healthcare and/or Health Insurance

Support for Meeting Economic and/or Housing Needs

Support for Mental Health

Any concerns about your child?

Answer required for "Any concerns about your child?"

PARENT/GUARDIAN 2 INFORMATION

Parent/Guardian 2 - First Name

Answer required for "Parent/Guardian 2 - First Name"

Parent/Guardian 2 - Last Name

Answer required for "Parent/Guardian 2 - Last Name"

Gender

Answer required for "Gender"

Female

Male

Prefer Not to Report

Date of Birth

Answer required for "Date of Birth"

If address is the same as Parent/Guardian 1, click box and skip to next question.

Answer required for "If address is the same as Parent/Guardian 1, click box and skip to next question. "

Same Address as Parent/Guardian 1

Address

Street Address

Answer required for "Street Address"

City

Answer required for "City"

State

Answer required for "State"

Zip/Postal

Answer required for "Zip/Postal"

Phone Number

Number Required

Email Address

Answer required for "Email Address"

Ethnicity

Answer required for "Ethnicity"

Hispanic/Latino

Non-Hispanic/Latino

Race

Answer required for "Race"

American Indian or Alaskan Native

Asian

Black or African America

Caucasian or White

Native Hawaiian

Prefer Not to Report

Other:

English Speaking?

Answer required for "English Speaking?"

Yes

Primary Language

Answer required for "Primary Language"

Marital Status

Answer required for "Marital Status"

Relationship to Child

Answer required for "Relationship to Child"

Highest Level of Education

Answer required for "Highest Level of Education"

Currently Enrolled In

Answer required for "Currently Enrolled In"

Current Employment

Answer required for "Current Employment"

Full Time

Part Time

Not Employeed

Current Housing

Answer required for "Current Housing"

Health Insurance

Answer required for "Health Insurance"

Dental Insurance

Answer required for "Dental Insurance"

Military Status (Select all that apply)

Answer required for "Military Status (Select all that apply)"

Active Duty

Reserves/National Guard

Non Applicable - Not in Military

Planning for Deployment

Returned from Deployment with in the past 2 years

CHILD 1 INFORMATION

Child 1

First Name

Answer required for "Child 1"

Last Name

Answer required for "Last Name"

Gender

Answer required for "Gender"

Male

Female

Prefer Not to Report

Prenatal

Date of Birth/Due Date if Prenatal*

Answer required for "Date of Birth/Due Date if Prenatal"

Ethnicity

Answer required for "Ethnicity"

Hispanic/Latino

Non-Hispanic/Latino

Race*

Answer required for "Race"

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian

Other Pacific Islander

Caucasian or White

Prefer Not to Report

English Speaking?

Answer required for "English Speaking?"

Yes

Primary Language*

Answer required for "Primary Language"

Health Insurance

Answer required for "Health Insurance"

Child Lives in the Home

Answer required for "Child Lives in the Home"

Yes

CHILD 2 INFORMATION

Child 2

First Name

Answer required for "Child 2"

Last Name

Answer required for "Last Name"

Gender

Answer required for "Gender"

Male

Female

Prenatal

Prefer Not to Report

Date of Birth/Due Date if Prenatal

Answer required for "Date of Birth/Due Date if Prenatal"

Ethnicity

Answer required for "Ethnicity"

Hispanic/Latino

Non-Hispanic/Latino

Race

Answer required for "Race"

American Indian or Alaskan Native

Black or African American

Native Hawaiian

Other Pacific Islander

Caucasian or White

Prefer Not to Report

English Speaking?

Answer required for "English Speaking?"

Yes

Primary Language

Answer required for "Primary Language"

Health Insurance

Answer required for "Health Insurance"

Child Lives in the Home

Answer required for "Child Lives in the Home"

Yes

CHILD 3 INFORMATION

Child 3

First Name

Answer required for "Child 3"

Last Name

Answer required for "Last Name"

Gender

Answer required for "Gender"

Male

Female

Prenatal

Prefer Not to Say

Date of Birth/Due Date if Prenatal

Answer required for "Date of Birth/Due Date if Prenatal"

Ethnicity

Answer required for "Ethnicity"

Hispanic/Latino

Non-Hispanic/Latino

Race

Answer required for "Race"

American Indian or Alaskan Native

Black or African American

Native Hawaiian

Other Pacific Islander

Caucasian or White

Prefer Not to Report

English Speaking?

Answer required for "English Speaking?"

Yes

Primary Language

Answer required for "Primary Language"

Health Insurance

Answer required for "Health Insurance"

Child Lives in Home

Answer required for "Child Lives in Home"

Yes

OTHER PEOPLE LIVING IN THE HOME

Person 1

Name (First & Last)

Answer required for "Person 1"

Gender

Answer required for "Gender"

Male

Female

Prefer Not to Say

Date of Birth

Answer required for "Date of Birth"

Relationship to Enrolled Child(ren)

Answer required for "Relationship to Enrolled Child(ren)"

Person 2

Name (First and Last)

Answer required for "Person 2"

Date of Birth

Answer required for "Date of Birth"

Gender

Answer required for "Gender"

Male

Female

Prefer Not to Say

Relationship to Enrolled Child(ren)

Answer required for "Relationship to Enrolled Child(ren)"

Person 3

Name (First and Last)

Answer required for "Person 3"

Gender

Answer required for "Gender"

Male

Female

Prefer Not to Say

Date of Birth

Answer required for "Date of Birth"

Relationship

Answer required for "Relationship"

Person 4

Name (First and Last)

Answer required for "Person 4"

Gender

Answer required for "Gender"

Male

Female

Prefer Not to Say

Date of Birth

Answer required for "Date of Birth"

Relationship to Enrolled Child(ren)

Answer required for "Relationship to Enrolled Child(ren)"

Referred By

Answer required for "Referred By"

Family Experiences: Strengths and Stressors (check all that apply)

Answer required for "Family Experiences: Strengths and Stressors (check all that apply)"

Parents who are pregnant or parenting under the age of 21.

Child has a significant delay, disability, or condition that impacts development and/or effects overall family well-being.

A parent has a physical or cognitive impairment (disability or chronic health condition) that substantially limits their ability to parent.

A parent has thought, mood, or behavioral disorder associated with distress and/or impaired functioning.

Child has serious behavior concerns.

Parent did not complete high school or pass an equivalency exam and is not currently enrolled.

Family is eligible for free and reduced lunches, public housing, child care subsidy, WIC, food stamps/SNAP, TANF, Head Start/Early Head Start, and/or Medicaid.

One or both parents is foreign-born and entered the country within the past five years. This does not include those from Puerto Rico, Guam, and the US Virgin Islands.

Parent has repeatedly used or is currently using substances despite negative social, interpersonal, legal, medical, or other consequences during child's lifetime.

Child or young parent is in foster care and has court-appointed legal guardians or is living in some other temporary caregiver situation.

Family lacks fixed, regular, and adequate nighttime residences, including those who share others' homes due to loss of housing or economic hardship; lives in motels, hotels, camping grounds due to lack of adequate alternative accommodations; resides in emergency or transitional shelters; or resides in public or private places not designed for or used for regular sleeping accommodations. n

Parent(s) is or was incarcerated in federal or state prison or local jail, halfway house or is part of a boot camp or weekend program requiring overnight stays during the child's lifetime.

The child's birth weight is under 3.5 pounds and the child was born at less than 37 weeks' gestational age.

The death of a child, parent/guardian, or sibling during child's lifetime.

Parent/Guardian is a survivor of intimate partner violence

Reported or substantiated abuse/neglect of child or sibling, including but not limited to a current or recent open case with the child welfare system for any reason.

Parent/Guardian is planning for deployment, currently deployed, or within two years of returning from a deployment as an active duty member of the armed forces.

Parent/Guardian has formerly served in the US Armed Forces.

Family speaks limited English.

School age children with low academic achievement.

Child is being parented by one parent in the home.

Three or more children under the age of 6.

Adoptive Parent.

First Time Parents.

Preferred Visit Time (Please note: You will have a longer wait time for an evening visit.)

Answer required for "Preferred Visit Time (Please note: You will have a longer wait time for an evening visit.)"

Day

Evening

Additional Comments:

Answer required for "Additional Comments:"

Family Income

Average Monthly Income

Answer required for "Average Monthly Income"

Number in Household Dependent on this Income

Answer required for "Number in Household Dependent on this Income"

Sources of Income

Answer required for "Sources of Income"

Child Support/Alimony

Energy Assistance

SNAP

Housing Assistance

Salary/Wages

Social Security/Disability

TANF

Unemployment

WIC

Other

Once submitted, this information will be sent to the Haysville USD 261 Parents as Teachers office. Someone from this office will be in contact with you. If you have any questions, please call the office at 316-554-2303.

Submitting form...

Protected by reCAPTCHA - Privacy - Terms

Please verify you are not a robot:

Please fix errors above