Parents As Teachers Enrollment

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Families with children birth to three years old.

The following information is kept for statistical purposes. It is highly confidential and not used to discriminate services. Please fill out to the best of your ability.

This form can be completed online or downloaded and mailed to:

Blue Valley Parents as Teachers
11600 Knox, Overland Park, Kansas 66210
Phone: (913) 239-4400
Questions? Email: Wendy Webb

Parent Information
Full Name *
Date of Birth *
Address *
City *
State *		Zip Code *
Email Address *
Home Number *	(  )    -
Cell Number *	(  )    -
Work Number *	(  )    -
Employer Name *
May We Call You at Work? *
	Yes No
Employment Status *
	Full Time Part Time Unemployed
Highest Level of Degree Awarded *
Other Information
Marital Status *
Language spoken in home?
Do you qualify for free or reduced lunch? *
	Yes No
What is the best time for a personal visit? *
	Day Time Evening Flexible
How did you hear about the program? *
Additional Parent Information
Full Name
Date of Birth
Address
City
State		Zip Code
Email Address
Home Number	(  )    -
Cell Number	(  )    -
Work Number	(  )    -
Employer Name
May We Call You at Work?
	Yes No
Employment Status
	Full Time Part Time Unemployed
Highest Level of Degree Awarded
Child Information (to be completed on child birth-age three)
Legal Name *
Due Date
Date of Birth *
Gender	Female Male
Child's Age at Call Date *
Prematurity
Birth Weight *
Please answer BOTH questions
Is your child Hispanic or Latino (choose only one)?
No, not Hispanic or Latino
Yes, Hispanic or Latino
What is your child's race (choose one or more)?
American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White
Sibling Information
Full Name
Date of Birth
Gender	Female Male
Additional Sibling Information
Full Name
Date of Birth
Gender	Female Male
Program Information
Have you ever received services with Parents as Teachers? *
	Yes No
If yes:	Where
	When
	Parent Educator
What services are you interested in? *
	Home Visits Group Meetings Drop In Playgroup Screenings Only
Additional Information or Comments

* Indicates a required field