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LECC PAT Enrollment Form
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Marital Status
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1st Parent's Name (First and Last Name)
Your answer
Phone Number
Your answer
email address
Your answer
2nd Parent's Name (First and Last Name)
Your answer
Phone number
Your answer
email address
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Home Address (include city, state, and zip code) If more than one address, please list all
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Are you new parents (is this your first child)?
Yes
No
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Child / Children's First and Last name
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Child / Children's Birthdate
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Ethnicity
Hispanic/Latino
Non-Hispanic/Latino
Prefer not to report
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Race
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American Indian or Alaskan Native
Asian
Black or African American
Hispanic/Latino
Non-Hispanic/Latino
Multi-race
Native Hawaiian
Other Pacific Islander
White
Prefer not to report
Other
Primary Language
Your answer
Secondary Language
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Are there any concerns with your child (at birth, speech delays, etc.)?
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Did you previously have a Parent Educator in Ladue? If so, who?
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Best time of day for visits?
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Interest in receiving information from LPA?
Yes
No
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Additional Comments:
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