Parents as Teachers at Great Beginnings Pre-Enrollment 2019-2020

Please note: The Parents as Teachers program is a free and voluntary program for families who reside in the Lee’s Summit R-7 school district with children prenatal to age 5 (pre-kindergarten).

THE INFORMATION YOU PROVIDE IS CONFIDENTIAL AND IS INTENDED SOLELY FOR THE PURPOSE OF DETERMINING SERVICES TO EACH INDIVIDUAL FAMILY.

Family Information
Parent/Guardian's Name #1 Parent/Guardian's Name #1 * First Last
Are you Hispanic/Latino *

Are you Hispanic/Latino Yes No
Ethnicity *
Marital Status *
Employment *
Last Grade Completed *
Parent/Guardian's Name #2 Parent/Guardian's Name #2 First Last
Are you Hispanic/Latino

Are you Hispanic/Latino Yes No
Ethnicity
Marital Status
Employment
Last Grade Completed

**When are you available for a Personal Home Visit? Please check all that apply:** *
	Monday	Tuesday	Wednesday	Thursday	Friday	Not Available
8:00 am - 12:00 pm	8:00 am - 12:00 pmMonday	8:00 am - 12:00 pmTuesday	8:00 am - 12:00 pmWednesday	8:00 am - 12:00 pmThursday	8:00 am - 12:00 pmFriday	8:00 am - 12:00 pmNot Available
12:00 - 3:00 pm	12:00 - 3:00 pmMonday	12:00 - 3:00 pmTuesday	12:00 - 3:00 pmWednesday	12:00 - 3:00 pmThursday	12:00 - 3:00 pmFriday	12:00 - 3:00 pmNot Available
4:00 pm or later	4:00 pm or laterMonday	4:00 pm or laterTuesday	4:00 pm or laterWednesday	4:00 pm or laterThursday	4:00 pm or laterFriday	4:00 pm or laterNot Available

Please provide additional helpful information for scheduling:
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone 1 Phone 1 * - ### - ### ####
Phone 2 Phone 2 - ### - ### ####
Phone 3 Phone 3 - ### - ### ####
Email
Attendance Area (This is the elementary school that the children in your neighborhood attend) *
Primary Language Spoken at home *
Secondary Language Spoken at home
How did you hear about Parents as Teachers? *
If you were previously in Parents as Teachers, who was your Parent Educator?
Would you like to request a Parent Educator? If so, please list name.
Is there a handicap or disability in the family? *

Is there a handicap or disability in the family? Yes No
Type/Nature
Family Member if applicable
Additional Family Characteristics. Please mark yes or no for each characteristic.

THE INFORMATION YOU PROVIDE IS CONFIDENTIAL AND IS INTENDED SOLELY FOR THE PURPOSE OF DETERMINING SERVICES FOR EACH INDIVIDUAL FAMILY.
Teen Parent(s) (Parent is under the age of 20 during the program year.) *

Teen Parent(s) (Parent is under the age of 20 during the program year.) Yes No
Child with disabilities or chronic health conditions (Child being served has a physical, cognitive, emotional or health-related condition or impairment that substantially limits one or more major life activities or qualifies the child for services under IDEA Part C.) *

Child with disabilities or chronic health conditions (Child being served has a physical, cognitive, emotional or health-related condition or impairment that substantially limits one or more major life activities or qualifies the child for services under IDEA Part C.) Yes No
Parent with disabilities or chronic health conditions (Parent has a physical, cognitive, other health-related condition or impairment that substantially limits one or more major life activities.) *

Parent with disabilities or chronic health conditions (Parent has a physical, cognitive, other health-related condition or impairment that substantially limits one or more major life activities.) Yes No
Parent with mental illness (Parent has been diagnosed with a thought, mood, or behavior disorder (or some combination) associated with distress and/or impaired functioning.) *

Parent with mental illness (Parent has been diagnosed with a thought, mood, or behavior disorder (or some combination) associated with distress and/or impaired functioning.) Yes No
Low Educational attainment (Parent did not complete high school or GED and is not currently enrolled. *

Low Educational attainment (Parent did not complete high school or GED and is not currently enrolled. Yes No
Low Income (Family is eligible for free and reduced lunches, public housing, child care subsidy, WIC, food stamps or Medicaid.) *

Low Income (Family is eligible for free and reduced lunches, public housing, child care subsidy, WIC, food stamps or Medicaid.) Yes No
Recent immigrant or refugee family (One or both parents are foreign-born and entered the country within the past five years.) *

Recent immigrant or refugee family (One or both parents are foreign-born and entered the country within the past five years.) Yes No
Substance Abuse (Parent has used or is currently using substances despite negative social, interpersonal, legal, medical, or other consequences.) *

Substance Abuse (Parent has used or is currently using substances despite negative social, interpersonal, legal, medical, or other consequences.) Yes No
Homeless or unstable housing (The family lives in emergency/transitional housing or in a place not intended for regular housing and/or moved more than twice in the past year.) *

Homeless or unstable housing (The family lives in emergency/transitional housing or in a place not intended for regular housing and/or moved more than twice in the past year.) Yes No
Incarcerated parent(s) (Parent is incarcareted in federal or state prison or local jail or was released from incarceration within the past year.) *

Incarcerated parent(s) (Parent is incarcareted in federal or state prison or local jail or was released from incarceration within the past year.) Yes No
Court appointed legal guardian(s) and/or foster care (Child is has court-appointed legal guardian(s) or is in foster care.) *

Court appointed legal guardian(s) and/or foster care (Child is has court-appointed legal guardian(s) or is in foster care.) Yes No
Very low birth rate (Birth weight is under 1500 grams or 3.3 pounds.) *

Very low birth rate (Birth weight is under 1500 grams or 3.3 pounds.) Yes No
Death in the immediate family (Child, parent or sibling has died.) *

Death in the immediate family (Child, parent or sibling has died.) Yes No
Domestic violence (Parent is involved in intimate partner violence.) *

Domestic violence (Parent is involved in intimate partner violence.) Yes No
Child abuse or neglect (Abuse/neglect of child or sibling is suspected or substantiated.) *

Child abuse or neglect (Abuse/neglect of child or sibling is suspected or substantiated.) Yes No
Single Parent Household (Only one parent/primary care giver resides in the home.) *

Single Parent Household (Only one parent/primary care giver resides in the home.) Yes No
Speakers of Other Languages/English Language Learners (A language other than English is the primary language spoken in the home.) *

Speakers of Other Languages/English Language Learners (A language other than English is the primary language spoken in the home.) Yes No
Military family (Parent/guardian is currently deployed or is within two years of returning from a deployment as an active duty member of the armed forces. *

Military family (Parent/guardian is currently deployed or is within two years of returning from a deployment as an active duty member of the armed forces. Yes No
Ongoing health problem of the child, parent, or sibling (Ongoing health problem is serious enough to substantially limit one or more major life activities.) *

Ongoing health problem of the child, parent, or sibling (Ongoing health problem is serious enough to substantially limit one or more major life activities.) Yes No
Child(ren)'s Information (Pre-natal - Pre-kindergarten)
Child 1 Information
Date of Birth Date of Birth * / MM / DD YYYY
Prenatal - Expected Delivery Date Prenatal - Expected Delivery Date / MM / DD YYYY
1st Child Full LEGAL Name on Birth Certificate 1st Child Full LEGAL Name on Birth Certificate * First Middle Last
Gender *

Gender Male Female
Birth Weight *
Child's Ethnicity *
Any illness/complications during pregnancy or delivery? *

Any illness/complications during pregnancy or delivery? Yes No
If yes, please explain *
Any illness/injury since birth *

Any illness/injury since birth Yes No
If yes, please explain *
Does Child attend a day-care or pre-school? *

Does Child attend a day-care or pre-school? Yes No
If yes, please list name of day-care or pre-school. *
Child 2 Information
Date of Birth Date of Birth / MM / DD YYYY
Prenatal - Expected Delivery Date Prenatal - Expected Delivery Date / MM / DD YYYY
2nd Child Full LEGAL Name on Birth Certificate 2nd Child Full LEGAL Name on Birth Certificate First Middle Last
Gender

Gender Male Female
Birth Weight
Child's Ethnicity
Any illness/complications during pregnancy or delivery?

Any illness/complications during pregnancy or delivery? Yes No
If yes, please explain *
Any serious illness/injury since birth?

Any serious illness/injury since birth? Yes No
If yes, please explain *
Does Child attend a day-care or pre-school?

Does Child attend a day-care or pre-school? Yes No
If yes, please list name of day-care or pre-school. *
Child 3 Information
Date of Birth Date of Birth / MM / DD YYYY
Prenatal - Expected Delivery Date Prenatal - Expected Delivery Date / MM / DD YYYY
3rd Child Full LEGAL Name on Birth Certificate 3rd Child Full LEGAL Name on Birth Certificate First Middle Last
Gender

Gender Male Female
Birth Weight
Child's Ethnicity
Any illness/complications during pregnancy or delivery?

Any illness/complications during pregnancy or delivery? Yes No
If yes, please explain *
Any serious illness/injury since birth?

Any serious illness/injury since birth? Yes No
If yes, please explain *
Does Child attend a day-care or pre-school?

Does Child attend a day-care or pre-school? Yes No
If yes, please list name of day-care or pre-school. *
Additional Family Information
Siblings not enrolled in the program that live in the home
Name Name First Last
Gender

Gender Male Female
Age
Name Name First Last
Gender

Gender Male Female
Age
Name Name First Last
Gender

Gender Male Female
Age
Any additional children (include Name, DOB, Gender) or additional information
Residents in the home other than immediate family Residents in the home other than immediate family First Last
Gender

Gender Male Female
Residents in the home other than immediate family Residents in the home other than immediate family First Last
Gender

Gender Male Female
Residents in the home other than immediate family Residents in the home other than immediate family First Last
Gender

Gender Male Female
Do you or someone else have concerns for your child's development? *

Do you or someone else have concerns for your child's development? Yes No
If yes, please explain? *
The Lee's Summit R-7 School District policy prohibits "all unlawful discrimination, including harassment creating a hostile environment, on the basis of race, color, religion, sex, national origin, ancestry, disability, age or use of leave protected by the Family and Medical Leave Act, in its programs, activities and with regard to employment." Accordingly, no information concerning race, ethnicity or sex that is requested during enrollment will be used to classify, segregate or otherwise deny any student the full benefit of the District's programs and activities.
Proof of Residency Document
(Please upload a current copy of a Gas, Water, or Electric Bill dated within the last 30 days. If providing a KCPL bill, we must receive both the front and back pages for verification.)

Attach Files
Proof of Age Document
(Please upload a copy of your child's birth certificate or other legal documentation of age and name.)

Attach Files

Parents as Teachers at Great Beginnings Pre-Enrollment 2019-2020

Parents as Teachers at Great Beginnings Pre-Enrollment 2019-2020

Family Information

Additional Family Characteristics. Please mark yes or no for each characteristic. THE INFORMATION YOU PROVIDE IS CONFIDENTIAL AND IS INTENDED SOLELY FOR THE PURPOSE OF DETERMINING SERVICES FOR EACH INDIVIDUAL FAMILY.

Child(ren)'s Information (Pre-natal - Pre-kindergarten) Child 1 Information

Child 2 Information

Child 3 Information

Additional Family Information

Siblings not enrolled in the program that live in the home

Additional Family Characteristics. Please mark yes or no for each characteristic.

THE INFORMATION YOU PROVIDE IS CONFIDENTIAL AND IS INTENDED SOLELY FOR THE PURPOSE OF DETERMINING SERVICES FOR EACH INDIVIDUAL FAMILY.

Child(ren)'s Information (Pre-natal - Pre-kindergarten)
Child 1 Information