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Parents As Teachers Enrollment

Families with children birth to 36 months.

To finish your enrollment please complete the following form. This information is kept for statistical purposes. It is confidential and will not be used to discriminate services.

Questions? Email: Michelle Kelly
Phone: (913) 624-2800

Items denoted with a red asterisk * are required.

Parent Information

Full Name *
Date of Birth *
Address *
City *
State *
Zip *
Email Address *
Home Number *
(###) ###-####
Cell Number *
(###) ###-####
Work Number *
(###) ###-####
Employer Name *
May we call you at work? *
Employment Status *
Highest Level of Degree Awarded

Other Information

Marital Status *
Were you or your spouse foreign born? *
If yes, date entered the United States
Language spoken in home?
Do you qualify for free or reduced lunch? *
What is the best time for a personal visit? *
How did you hear about the program? *

Additional Parent Information

Full Name
Date of Birth
Address
City
State
Zip
Email Address
Home Number
(###) ###-####
Cell Number
(###) ###-####
Work Number
(###) ###-####
Employer Name
May we call you at work?
Employment Status
Highest Level of Degree Awarded

Child Information

Legal First Name *
Legal Middle Name *
Legal Last Name *
Due Date
Date of Birth *
Gender
Child's Age at Call Date *
Prematurity
Birth Weight *
Please Answer ALL 3 questions
Is your child's immunization current as of today's date? *
Is your child Hispanic or Latino (choose only one)? *
What is your child's race? *

Sibling Information

Full Name
Date of Birth
Gender

Additional Sibling Information

Full Name
Date of Birth
Gender

Program Information

Have you ever received services with Parents as Teachers? *
If yes:
Where
When
Parent Educator
What services are you interested in? *

Additional Information or Comments?

Blue Valley Parents as Teachers informs, supports and encourages you in your parenting role. Our services are designed to help you learn more about parenting and your child's development, help you cope with the challenges of family life, and help identify and address any potential delays in your child's development. Together, you and the parent educator will focus on ways you can interact with your child to support his or her development, work through your parenting questions and concerns, and build a healthy environment for your child.

Routine information will be collected during your participation in the program. Parent educators are "mandated reporters." This means that by laws they must make a report to protect your family's safety if there are concerns about child abuse or neglect, domestic violence, elder abuse, or intent to harm self or others. With exception of this type of information, all your information will be kept confidential and will not be released outside the program without your written permission or a court order.

Your parent educator agrees to:

- Schedule a minimum of ten home visits a year at a convenient time for parents and parent educator.
- Provide research based developmental information and evidence based parenting practices.
- Invite your family to group connections throughout the year.
- Offer annual screenings (development, health, hearing and vision).
- Connect your family to resources as needed or requested.
- Help you set and work on your family goals.

Your family agrees to:

- Actively engage with your child and parent educator in a minimum of ten home visits this year.
- Attend a minimum of one group connection or playgroup this year.
- Minimize distractions during the personal visit (television, phones, pets, etc.)
- Set period family/child goals.
- Provide feedback to the program by completing the annual satisfaction survey.

The limits of our services:
Parent educators are not psychologists or medical professionals. We do not diagnose developmental, psychological, or medical conditions. However, we can help you connect to qualified professionals and resources that can assist in these situations.

Agreement *

If you do not receive a follow up email from Parents as Teachers regarding this enrollment in the next two weeks please call (913) 624-2800.

 
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Title

ParentFullName *

ParentDOB *

ParentAddress *

ParentCity *

ParentState *

ParentZip *

ParentEmailAddress *

ParentHomePhone *

ParentCellPhone *

ParentWorkPhone *

ParentEmployer *

ParentCallWork *

ParentEmploymentStatus *

ParentDegree *

ParentMaritalStatus *

ParentForeignBorn *

ParentForeignBornYes

ParentHomeLanguage

ParentFreeOrReduced *

ParentPersonalVisit *

ParentHearAboutProgram *

Parent2FullName

Parent2DOB

Parent2Address

Parent2City

Parent2State

Parent2Zip

Parent2EmailAddress

Parent2HomePhone

Parent2CellPhone

Parent2WorkPhone

Parent2Employer

Parent2CallWork

Parent2EmploymentStatus

Parent2Degree

ChildFirstName *

ChildMiddleName *

ChildLastName *

ChildDueDate

ChildDOB *

ChildGender

ChildAgeAtCallDate *

ChildPrematurity

ChildBirthWeight *

ChildImmunization *

ChildEthnicity *

ChildRace *

SiblingFullName

SiblingDOB

SiblingGender

Sibling2FullName

Sibling2DOB

Sibling2Gender

ParentsAsTeachersServices *

ParentsAsTeachersServicesWhere

ParentsAsTeachersServicesWhen

ParentsAsTeachersServicesEducator

ServicesInterestedIn *

AdditionalInfo

Agreement *

Attachments