PAT Enrollment Form

Please take a few minutes to complete this registration form. After you have submitted the enrollment form, Jamie Fink, the Parents as Teachers Coordinator will contact you to schedule a time for your initial visit. In order to match you with a Parent Educator, we would appreciate your BEST estimate of when you will be available for visits until your child is 3 years old. On the form below, please mark the time you will be available for ongoing visits. Please contact Jamie Fink, Coordinator, at jfink@usd232.org if you have any questions. The information submitted through the enrollment form is confidential and is not used to discriminate services. Please complete the form to the best of your ability.

1.	Parent/Guardian #1 Name (first, last)*

2.	Parent/Guardian #1 Date of Birth
	mm/dd/yyyy

3.	Parent/Guardian #1 Employment Status
	Parent/Guardian #1 Employment Status Full time Part time Unemployed

4.	Parent/Guardian #1 highest education level obtained
	--None--High School diplomaSome collegeCollege degreeOther

5.	Parent #1 Ethnicity
	--None--Hispanic/LatinoNot Hispanic/Latino

6.	Parent/Guardian #1 race
	--None--American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite

7.	Parent/Guardian #2 Name (first, last)*

8.	Parent/Guardian #2 Date of Birth
	mm/dd/yyyy

9.	Parent/Guardian #2 Employment Status
	Parent/Guardian #2 Employment Status Full time Part time Unemployed

10.	Parent/Guardian #2 highest education level obtained
	--None--High School diplomaSome collegeCollege degreeOther

11.	Parent #2 Ethnicity
	--None--Hispanic/LatinoNot Hispanic/Latino

12.	Parent/Guardian #2 race
	--None--American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite

13.	Address (include city and zip code)

14.	Email Address *

15.	Type of email address*
	Type of email address* Home Work

16.	Alternate Email Address

17.	Type of email address
	Type of email address Home Work

18.	Best phone number for us to contact you

19.	Phone Type*
	Phone Type* Home Work

20.	Alternate Phone Number

21.	Phone Type
	Phone Type Home Work

22.	How do you prefer to be contacted?
	How do you prefer to be contacted? Email Phone Text

23.	Is either parent a first-time parent of a child under the age of three?
	Is either parent a first-time parent of a child under the age of three? Yes No

24.	Marital status

25.	With whom does the child primarily live with?
	With whom does the child primarily live with? Both parents Mom Dad Guardian Other Other, please specify

26.	Tell us the best day of the week for ongoing visits (Monday-Friday).
	Monday    Tuesday    Wednesday    Thursday    Friday

27.	Availability for visits until your child is three years of age Visits from 4-7 PM are for parents who both work full-time outside the home. If parents are available to visit before 4pm, they will be paired up with a parent educator sooner.
	Availability for visits until your child is three years of age Visits from 4-7 PM are for parents who both work full-time outside the home. If parents are available to visit before 4pm, they will be paired up with a parent educator sooner. Day, 7:00 a.m. - 4:00 p.m. Evening, 5:00 p.m. - 7:00 p.m. Flexible

28.	Is either parent foreign born?
	--None--Yes No

29.	If YES, which country?

30.	What is the parent's primary language?

31.	What is the primary language spoken in the home?

32.	What other language is spoken in the home?

33.	Type of Insurance
	Type of Insurance Private State None

34.	Total household income before taxes during the last 12 months
	Total household income before taxes during the last 12 months Less than $25,000 $25,000 to $34,999 $35,000 to $49,999 $50,000 to 74,999 $75,000 to $99,999 $100,000 to $149,000 $150,000 to $199,999 $200,000 or more

35.	What is the family's housing status?
	What is the family's housing status? Owns home Rents home Lives with relative

36.	Is either parent currently a student?
	--None--Yes No