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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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* Indicates required question
Parent/Guardian #1 Information
Parent Full Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Gender
*
Your answer
Relationship to Child
*
Choose
Mother
Father
Grandparent
Stepparent
Foster Parent
Legal Guardian
Other
Current Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip
*
Your answer
Housing Status
*
Choose
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
Your answer
Email
*
Your answer
Contact Phone Number
*
Your answer
Accept Texts?
*
Yes
No
Employment Status
*
Choose
Full Time
Part Time
Not Employed
Prefer Not to Say
Name of Employer
*
Your answer
Marital Status
*
Choose
Never Married
Married
Widowed
Divorced
Separated
Not Married But Living with Partner
Other
Prefer Not to Say
Primary Language
*
Your answer
Secondary Language (
if applicable
)
Your answer
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
Required
Level of Education
*
Choose
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
Choose
Private
State
Medicaid
Other
None
Location for Regular Medical Checkups
Choose
Urgent Care
Emergency Room
Clinic
Primary Care Physician
Other
Recent Emergency Room Visits
Your answer
Military Service
*
Choose
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
Required
How did you hear about our program?
*
Your answer
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
Your answer
Date of Birth
MM
/
DD
/
YYYY
Gender
Your answer
Relationship to the Child
Choose
Mother
Father
Grandparent
Stepparent
Foster Parent
Legal Guardian
Other
Email
Your answer
Contact Phone Number
Your answer
Accept Texts?
Yes
No
Clear selection
Employment Status
Choose
Full Time
Part Time
Not Employed
Prefer Not to Say
Name of Employer
Your answer
Marital Status
Choose
Never Married
Married
Widowed
Divorced
Separated
Not Married But Living With Partner
Other
Prefer Not to Say
Primary Language
Your answer
Secondary Language (
if applicable
)
Your answer
Ethnicity
Hispanic
Non-Hispanic
Clear selection
Race
American Indian/Alaskan Native
Black or African American
Asian
Hawaiian or Other Pacific Islander
White
Other
Prefer Not to Say
Level of Education
Choose
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
*
Your answer
Relationship of Emergency Contact
*
Your answer
Phone Number of Emergency Contact
*
Your answer
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
)
*
Your answer
If currently expecting, what is your due date?
MM
/
DD
/
YYYY
Child's Date of Birth
*
MM
/
DD
/
YYYY
Gender
*
Your answer
Child's Age at Enrollment
*
Your answer
Birth Weight
*
Your answer
Birth Length
*
Your answer
Was your child born premature?
*
Yes
No
Any complications with birth or delivery? If yes, please describe.
*
Your answer
Any current medical conditions? If yes, please describe.
*
Your answer
Ethnicity
*
Hispanic
Non-Hispanic
Race
*
Choose
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
*
Your answer
Child's Secondary Language (
if applicable
)
Your answer
Child's Healthcare Provider (if none, mark as N/A)
*
Your answer
Approximate Date of Last Checkup
*
MM
/
DD
/
YYYY
Do you choose to have your child immunized?
*
Choose
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?
*
Choose
Yes- the child's immunizations are current.
No- the child's immunizations are not current.
Prefer Not to Say
Type of Insurance for Child
*
Choose
Private
State
Other
No Insurance
Prefer Not to Say
With whom does the child reside?
*
Choose
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.
*
Your answer
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
Your answer
Does the child attend daycare?
*
Choose
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)
*
Your answer
Have you received services from Parents as Teachers before?
*
Yes
No
Average Monthly Income
Your answer
Source of Income
Your answer
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