LENA Home Caregiver Interest Form

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Each adult caregiver may enroll with one child. All children must be 2-48 months of age to participate in LENA Home.

Email *

Thank you for your interest in LENA. LENA is a Language ENvironment Analysis (LENA) program that uses a talk pedometer to measure how many words your young child actually hears in a day. This "Talk Builds Baby's Brain Program," consists of parental support to enhance your child's social emotional development while building an environment for advanced early talk. How do you plan to attend weekly online Zoom conference LENA sessions? *

Caregiver First & Last Name *

Please enter your full name.

TN Mailing Address *

Please enter your full mailing address with unit number if applicable, City, State and Zip code.

Has the child you are enrolling ever participated in a LENA program prior? LENA Home, Start or Grow? *

Yes

Relationship to child *

Mother

Grandmother

Aunt

Father

Grandfather

Uncle

Other:

Adult Caregiver's Date of Birth *

YYYY

Phone number *

Phone number 2 *

Choose which day works best for you below, when you can be alone for an hour one day per week? *

Each session will meet 1 day per week for 12 weeks. Mandatory attendance is required sessions 1-4. You must attend 8 of 10 session to graduate. Weekly incentives are awarded after each session. Monthly sessions are awarded after 4 consecutive attendances. Choose which day and time frame works best for you.

8:00 am - 10:00 am

10:00 am -12:00 pm

12:00 - 2:00 pm

2:00- 4:00 pm

4:00 - 6:00 pm

6:00 - 8:00 pm

Monday

Tuesday

Wednesday

Thursday

Friday

Child's First Name *

Child's Last Name *

Is the child enrolled in a childcare program? *

Yes

If the child enrolled in a childcare program, what is the name of the program where the child is enrolled? Write N/A if not enrolled. *

Does the child have a diagnosed developmental disability or do you suspect the child has a developmental disability? *

Yes

Unsure

Child's gender *

Male

Female

Child's date of birth *

YYYY

Child's age in months *

Child's Diaper or Pull up size *

Milk or Formula type *

Are there other children under age 18 in the home? *

Yes

How did you hear about us? *

To participate in the program you will process your LENA device with LENA Family Hub App once weekly. You must first run the installer on a computer, tablet or laptop. Will you be able to download the app to a device you have access to once a week? Visit https://www.lena.org/familyhub/ *

Yes

Join the Project Memphis group on Remind.com for LENA and community updates. Text @bab8h2 to the number 81010. Click yes once you have joined. *

Yes

Send me a copy of my responses.

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