Parents as Teachers Application Step 1 of 5 20% Pregnant*YesNoDue Date* Date Format: MM slash DD slash YYYY Child 1 InformationName* First Last Birthday* Date Format: MM slash DD slash YYYY Sex*MaleFemalePrimary Language*Secondary LanguageDoes your child have any disability or special need? (either diagnosed or suspected)*YesNoDo you have concerns about your child’s development?**YesNoExplain*Does your child have an IEP or an IFSP?*YesNoDoes your child have a sibling in the program?**YesNoAdd Additional Child?YesNo Child 2 InformationName* First Last Brithday* Date Format: MM slash DD slash YYYY Sex*MaleFemalePrimary Language*Secondary LanguageDoes your child have any disability or special need? (either diagnosed or suspected)**YesNoDo you have concerns about your child’s development?**YesNoExplain*Does your child have an IEP or an IFSP?**YesNoDoes your child have a sibling in the program?**YesNo Parent/Guardian InformationName* First Last Birthdate* Date Format: MM slash DD slash YYYY Relationship to child(ren)*MotherFatherGrandparentFoster parentEmployment 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?*YesNoEmail* Primary Language*Secondary LanguageParental Status*OneTwoFamily Type*ParentGrandparentFosterNumber 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?*YesNoHas your child previously been enrolled in any Kids’ Corps program?*YesNoFamily Housing Status*RentOwnHomelessHas your family experienced homelessness in the past 6 months?*YesNoAre you receiving ATAP?*YesNoIs your family experiencing a special hardship or crisis?*YesNoExplain*Were you referred by another agency or provider?*YesNoWho referred you?*How did you hear about KCI?*Friend or neighborHead Start busKCI brochureRadioDoor hangerCommunity EventAgency 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*
