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.
Child Abuse or Neglect (Reported or substantiated abuse/neglect of child or sibling, including but not limited to a current or recent open case with the child welfare system for any reason). *

Child Abuse or Neglect (Reported or substantiated abuse/neglect of child or sibling, including but not limited to a current or recent open case with the child welfare system for any reason). Yes No
Child with Disability or Chronic Health Condition (The child has a significant delay, disability, or condition that impacts developmental domains and/or effects overall family well-being). *

Child with Disability or Chronic Health Condition (The child has a significant delay, disability, or condition that impacts developmental domains and/or effects overall family well-being). Yes No
Death in the Immediate Family (The death of a child, parent or sibling. Programs have discretion in determining how far back in time is relevant. PATNC recommends including this as a risk factor if a death in the immediate family has occurred at any point during the enrolled child’s lifetime (including prenatal). *

Death in the Immediate Family (The death of a child, parent or sibling. Programs have discretion in determining how far back in time is relevant. PATNC recommends including this as a risk factor if a death in the immediate family has occurred at any point during the enrolled child’s lifetime (including prenatal). Yes No
Foster Care or Other Temporary Caregiver (Child or young parent is in foster care or has Court-appointed legal guardians or is living in some other temporary caregiver condition). *

Foster Care or Other Temporary Caregiver (Child or young parent is in foster care or has Court-appointed legal guardians or is living in some other temporary caregiver condition). Yes No
High School Diploma or Equivalency not Attained (Parent did not complete high school or pass an Equivalency exam and is not currently enrolled). *

High School Diploma or Equivalency not Attained (Parent did not complete high school or pass an Equivalency exam and is not currently enrolled). Yes No
Housing Instability (Individuals who are homeless lack fixed, regular, and adequate nighttime residences, including those who share others homes due to loss of housing or economic hardship; live in motels, Hotels, or camping grounds due to lack of adequate alternative accommodations; reside in emergency or transitional shelters; or reside in public or private places not designated for or used as regular sleeping accommodations). *

Housing Instability (Individuals who are homeless lack fixed, regular, and adequate nighttime residences, including those who share others homes due to loss of housing or economic hardship; live in motels, Hotels, or camping grounds due to lack of adequate alternative accommodations; reside in emergency or transitional shelters; or reside in public or private places not designated for or used as regular sleeping accommodations). Yes No
Intimate Partner Violence (Parent/guardian is a survivor of intimate partner violence per self-report, positive screening, or court proceedings. This includes physical, sexual, and psychological violence. Economic coercion against a current or former intimate partner is also included. PATNC recommends including this as a risk factor if intimate partner violence has occurred during the child’s lifetime (including prenatal). *

Intimate Partner Violence (Parent/guardian is a survivor of intimate partner violence per self-report, positive screening, or court proceedings. This includes physical, sexual, and psychological violence. Economic coercion against a current or former intimate partner is also included. PATNC recommends including this as a risk factor if intimate partner violence has occurred during the child’s lifetime (including prenatal). Yes No
Low Income (Family is eligible for free and reduced priced lunches, public housing, child care subsidy, WIC, food stamps/SNAP, TANF, Head Start/Early Head Start and/or Medicaid). *

Low Income (Family is eligible for free and reduced priced lunches, public housing, child care subsidy, WIC, food stamps/SNAP, TANF, Head Start/Early Head Start and/or Medicaid). Yes No
Military Deployment (Parent/guardian is planning for deployment, currently deployed, or within two years of returning from a deployment as an active duty member of the armed forces). *

Military Deployment (Parent/guardian is planning for deployment, currently deployed, or within two years of returning from a deployment as an active duty member of the armed forces). Yes No
Parent Incarcerated during the Child’s Lifetime (Parent(s) is or was incarcerated in federal or state prison or local jail, halfway house or is part of a boot camp or weekend program requiring overnight stays during the child’s lifetime). *

Parent Incarcerated during the Child’s Lifetime (Parent(s) is or was incarcerated in federal or state prison or local jail, halfway house or is part of a boot camp or weekend program requiring overnight stays during the child’s lifetime). Yes No
Parent with Disabilities or Chronic Health Condition (A parent has a physical or cognitive impairment (disability or chronic health condition) that substantially limits their ability to parent as determined by the parent or by the parent educator). *

Parent with Disabilities or Chronic Health Condition (A parent has a physical or cognitive impairment (disability or chronic health condition) that substantially limits their ability to parent as determined by the parent or by the parent educator). Yes No
Parent with Mental Health Issue(s) (A parent has a thought, mood, or behavioral disorder (or some Combination) associated with distress and/or impaired functioning, as determined by parent report, positive screening, or a diagnosis). *

Parent with Mental Health Issue(s) (A parent has a thought, mood, or behavioral disorder (or some Combination) associated with distress and/or impaired functioning, as determined by parent report, positive screening, or a diagnosis). Yes No
Recent Immigrant or Refugee Family (One or both parent are foreign-born and entered the country within the past 5 years. This does not include those from Puerto Rico, Guam, and the U.S. Virgin Islands. *

Recent Immigrant or Refugee Family (One or both parent are foreign-born and entered the country within the past 5 years. This does not include those from Puerto Rico, Guam, and the U.S. Virgin Islands. Yes No
Single Parent Household* (Only one parent resides in the home). *

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

Speakers of Other Languages/English Learners* (A language other than English is the primary language spoken in the home. Yes No
Substance Use Disorder (Parent persistently has used or is currently using substances despite negative social, interpersonal, legal medical or other consequences. Programs have discretion in determining how far back in time is relevant in terms of current impact on parenting, family well-being, or the parent child relationship. PATNC recommends including this as a risk factor if substance abuse has occurred at any point during the enrolled child’s lifetime (including prenatal). *

Substance Use Disorder (Parent persistently has used or is currently using substances despite negative social, interpersonal, legal medical or other consequences. Programs have discretion in determining how far back in time is relevant in terms of current impact on parenting, family well-being, or the parent child relationship. PATNC recommends including this as a risk factor if substance abuse has occurred at any point during the enrolled child’s lifetime (including prenatal). Yes No
Very Low Birth Weight and Preterm Birth (The child’s birth weight is under 1500 grams or 3.5 pounds and the child was born at less than 37 weeks’ gestation for children under the age of 2). *

Very Low Birth Weight and Preterm Birth (The child’s birth weight is under 1500 grams or 3.5 pounds and the child was born at less than 37 weeks’ gestation for children under the age of 2). Yes No
Young Parent (Teen Parents) (Youth who are pregnant or parenting under the age of 21. *

Young Parent (Teen Parents) (Youth who are pregnant or parenting under the age of 21. 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