Parents as Teachers Application Step 1 of 5 20% Pregnant* Yes No Due Date* MM slash DD slash YYYY Child 1 InformationName* First Last Birthday* MM slash DD slash YYYY Sex* Male Female Primary Language* Secondary Language Does your child have any disability or special need? (either diagnosed or suspected)* Yes No Do you have concerns about your child’s development?** Yes No Explain*Does your child have an IEP or an IFSP?* Yes No Does your child have a sibling in the program?** Yes No Add Additional Child? Yes No Child 2 InformationName* First Last Brithday* MM slash DD slash YYYY Sex* Male Female Primary Language* Secondary Language Does your child have any disability or special need? (either diagnosed or suspected)** Yes No Do you have concerns about your child’s development?** Yes No Explain*Does your child have an IEP or an IFSP?** Yes No Does your child have a sibling in the program?** Yes No Parent/Guardian InformationName* First Last Birthdate* MM slash DD slash YYYY Relationship to child(ren)* Mother Father Grandparent Foster parent Employment Status*Check all that apply Full-Time Part-Time Unemployed In School/Training Home Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Mailing Address (if different) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Primary Phone*Phone Type*Select One...MobileHomeSecondary PhonePhone TypeSelect One...MobileHomeMay we contact you by text message?* Yes No Email* Primary Language* Secondary Language Parental Status* One Two Family Type* Parent Grandparent Foster Number in family*Number of Children Ages 0 - 35 Months*Number of Children Ages 3 - 5 Years*Total Number of Persons In Home* Parent/Guardian Information continued...Are you a teen parent?* Yes No Has your child previously been enrolled in any Kids’ Corps program?* Yes No Family Housing Status* Rent Own Homeless Has your family experienced homelessness in the past 6 months?* Yes No Are you receiving ATAP?* Yes No Is your family experiencing a special hardship or crisis?* Yes No Explain*Were you referred by another agency or provider?* Yes No Who referred you?* How did you hear about KCI?* Friend or neighbor Head Start bus KCI brochure Radio Door hanger Community Event Agency referral Digital SignatureKids’ Corps, Inc. – Parents As Teachers 101 Davis St. Anchorage, AK 99508 Phone: 907-339-0154 Fax: 907-339-0148 Email: pat@kcialaska.org I certify that this information is true. If any part is false, my participation in this agency’s programs may be terminated and I may be subject to legal action. I also understand that the information in this application will be held in strict confidence within the agency and is accessible to me during normal business hours. By typing my name in the field below, I certify that the information provided in this application packet contains no willful misrepresentation or falsification and that the information given by me is true and complete to the best of my knowledge. Electronic Signature* CAPTCHA Δ
