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Liberty Parents as Teachers Enrollment Form 20-21
Thank you for your interest in the Liberty Parents As Teachers program. A parent educator will be in contact to follow-up on your enrollment. Thank you!
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* Indicates required question
Email
*
Your email
Child's First & Last Name
*
Your answer
Gender
*
Choose
Male
Female
Child's Date of Birth
*
Your answer
Family Street Address, City and Zip Code
*
Your answer
Family Phone Number include area code
*
Your answer
Visit Preference
*
Day (8am-3pm)
Evening (3pm-7pm)
Preferred Method of Contact
*
Phone
Email
Mother's Name (First and Last)
*
Your answer
Father's Name (First and Last)
*
Your answer
Guardian's Name (First and Last)
Your answer
Are There Any Other Children In The Home? If yes, please provide information regarding siblings.
*
Yes
No
Sibling #1 First and Last Name
Your answer
Sibling #1 Birth Date
MM
/
DD
/
YYYY
Sibling #2 First and Last Name
Your answer
Sibling #2 Birth Date
MM
/
DD
/
YYYY
Sibling #3 First and Last Name
Your answer
Sibling #3 Birth Date
MM
/
DD
/
YYYY
Sibling #4 First and Last Name
Your answer
Sibling #4 Birth Date
MM
/
DD
/
YYYY
Please Indicate All Categories That Apply To Your Family
Teen Parent(s)
Child With Disabilities Or Chronic Health Conditions
Parent With Disabilities or Chronic Health Conditions
Parent With Mental Illness
Parent Did Not Complete High School Or GED And Is Not Currently Enrolled In School
Low Income
Recent Immigrant of Refugee Family
Substance Abuse
Court Appointed Legal Guardians and /or Foster Care
Homeless or Unstable Housing
Incarcerated Parent(s)
Very Low Birth Weight (Child was born under 3.3 pounds)
Death In The Immediate Family
Domestic Abuse
Child Abuse or Neglect
Military Family-parent/guardian is currently deployed or has been deployed within the last 2 years
Ongoing Health Problem of the Child, Parent, or Sibling
First Time Parent
Both Parents Work Outside the Home
Family/Children Uninsured
Single parent household
Name of Person Completing Form
*
Your answer
A copy of your responses will be emailed to the address you provided.
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