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Parents as Teachers Enrollment
Thank you for your interest in Auburn-Washburn Parents as Teachers. The following questions will help us gather information in order to best support your family. All answers are kept confidential. The information we gather will allow your parent educator to tailor your home visits to meet the specific needs of your family. Should you have any questions regarding the information that is being collected or have any technical issues with the enrollment process please call our office at 785-339-4762. Parents as Teachers is a free program to all families with young children residing in the Auburn-Washburn school district boundaries. The program does not discriminate based on any information provided.
Items denoted with an asterisk (*) are required.
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* Gibt eine erforderliche Frage an
Parent/Guardian #1 Information
Parent Full Name
*
Meine Antwort
Date of Birth
*
TT
.
MM
.
JJJJ
Gender
*
Meine Antwort
Relationship to Child
*
Auswählen
Mother
Father
Grandparent
Stepparent
Foster Parent
Legal Guardian
Other
Current Address
*
Meine Antwort
City
*
Meine Antwort
State
*
Meine Antwort
Zip
*
Meine Antwort
Housing Status
*
Auswählen
Homeless and sharing housing
Homeless and living in transitional housing
Living in public housing
Living with family
Not homeless- in some other living arrangement
Rents or shares own home or apartment
Owns or shares own home or apartment
Other living arrangements not otherwise specified
Prefer Not to Say
Length of Time At Current Address
Meine Antwort
Email
*
Meine Antwort
Contact Phone Number
*
Meine Antwort
Accept Texts?
*
Yes
No
Employment Status
*
Auswählen
Full Time
Part Time
Not Employed
Prefer Not to Say
Name of Employer
*
Meine Antwort
Marital Status
*
Auswählen
Never Married
Married
Widowed
Divorced
Separated
Not Married But Living with Partner
Other
Prefer Not to Say
Primary Language
*
Meine Antwort
Secondary Language (
if applicable
)
Meine Antwort
Ethnicity
*
Hispanic
Non-Hispanic
Race
*
American Indian/Alaskan Native
Black or African American
Asian
Hawaiian or Other Pacific Islander
White
Other
Prefer Not to Say
Pflichtfrage
Level of Education
*
Auswählen
Less Than High School
High School Diploma
GED
Some College
Associate's Degree
Bachelor's Degree or Higher
Vocational/Technical Training
Other
Prefer Not to Say
Type of Insurance for the Parent
Auswählen
Private
State
Medicaid
Other
None
Location for Regular Medical Checkups
Auswählen
Urgent Care
Emergency Room
Clinic
Primary Care Physician
Other
Recent Emergency Room Visits
Meine Antwort
Military Service
*
Auswählen
Yes- Current
Yes- Former
No- Never Served
Other
Prefer Not to Say
~PAT strives to serve as many families as possible with home visits. Due to time constraints there will always be less time slots available for families who can only meet after 4 pm than for families who have availability between 8am-4pm.~
Keeping the above information in mind, what time works best for your family to schedule a home visit?
*
Mornings (8am-12pm)
Afternoons (12pm-4pm)
Evenings (after 4pm)
Are there particular days of the week that work best for your family?
*
Monday
Tuesday
Wednesday
Thursday
Friday
Pflichtfrage
How did you hear about our program?
*
Meine Antwort
Parent/Guardian #2 Information
If parent/guardian #2 is involved please provide as much information as you are comfortable sharing. If parent/guardian #2 is NOT involved skip down to Emergency Contact Information section.
Is Parent/Guardian #2 involved?
*
Yes
No
Parent #2 Full Name
Meine Antwort
Date of Birth
TT
.
MM
.
JJJJ
Gender
Meine Antwort
Relationship to the Child
Auswählen
Mother
Father
Grandparent
Stepparent
Foster Parent
Legal Guardian
Other
Email
Meine Antwort
Contact Phone Number
Meine Antwort
Accept Texts?
Yes
No
Auswahl löschen
Employment Status
Auswählen
Full Time
Part Time
Not Employed
Prefer Not to Say
Name of Employer
Meine Antwort
Marital Status
Auswählen
Never Married
Married
Widowed
Divorced
Separated
Not Married But Living With Partner
Other
Prefer Not to Say
Primary Language
Meine Antwort
Secondary Language (
if applicable
)
Meine Antwort
Ethnicity
Hispanic
Non-Hispanic
Auswahl löschen
Race
American Indian/Alaskan Native
Black or African American
Asian
Hawaiian or Other Pacific Islander
White
Other
Prefer Not to Say
Level of Education
Auswählen
Less Than High School
High School Diploma
GED
Some College
Associate's Degree
Bachelor's Degree or Higher
Vocational/Technical Training
Other
Prefer Not to Say
Emergency Contact Information
Please provide us with contact information for at least one other individual that can be reached in an emergency situation.
Emergency Contact Name
*
Meine Antwort
Relationship of Emergency Contact
*
Meine Antwort
Phone Number of Emergency Contact
*
Meine Antwort
Child Information
Please fill out information for at least one child in the family that is 3 years or under in the Child Information area below. Information for additional children in the home will be completed at the initial enrollment visit.
Child Full Name (
Please include middle name if applicable
)
*
Meine Antwort
If currently expecting, what is your due date?
TT
.
MM
.
JJJJ
Child's Date of Birth
*
TT
.
MM
.
JJJJ
Gender
*
Meine Antwort
Child's Age at Enrollment
*
Meine Antwort
Birth Weight
*
Meine Antwort
Birth Length
*
Meine Antwort
Was your child born premature?
*
Yes
No
Any complications with birth or delivery? If yes, please describe.
*
Meine Antwort
Any current medical conditions? If yes, please describe.
*
Meine Antwort
Ethnicity
*
Hispanic
Non-Hispanic
Race
*
Auswählen
American Indian/Alaskan Native
Black or African American
Asian
Native Hawaiian or Other Pacific Islander
White
Other
Prefer Not to Say
Child's Primary Language
*
Meine Antwort
Child's Secondary Language (
if applicable
)
Meine Antwort
Child's Healthcare Provider (if none, mark as N/A)
*
Meine Antwort
Approximate Date of Last Checkup
*
TT
.
MM
.
JJJJ
Do you choose to have your child immunized?
*
Auswählen
Yes- we follow the recommended immunization schedule
Yes- we follow a modified immunization schedule
No- we choose not to immunize
No- my child is unable to be immunized
Prefer Not to Say
Are the child's immunizations current as of the date this form is being completed?
*
Auswählen
Yes- the child's immunizations are current.
No- the child's immunizations are not current.
Prefer Not to Say
Type of Insurance for Child
*
Auswählen
Private
State
Other
No Insurance
Prefer Not to Say
With whom does the child reside?
*
Auswählen
Both Parents
Mother
Father
Legal Guardian
Joint Responsibility
Foster Parents
Other Living Arrangement
Prefer Not to Say
Does the child participate in other programs? (
examples: center based preschool program, Head Start, daycare, parent/tot classes, etc.
) If yes, please explain.
*
Meine Antwort
Are there additional children in the home? (
if yes, please include their information below
)
*
Yes
No
Name(s), age(s) and birthdate(s) of other children in the home
Meine Antwort
Does the child attend daycare?
*
Auswählen
Yes- licensed daycare center
Yes- licensed home daycare
Yes- unlicensed daycare facility
No- my child does not attend daycare
Prefer not to say
Residents living in the home other than immediate family? (If no, please put N/A)
*
Meine Antwort
Have you received services from Parents as Teachers before?
*
Yes
No
Average Monthly Income
Meine Antwort
Source of Income
Meine Antwort
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