Program SurveyPlease enable JavaScript in your browser to complete this form.Parent InformationName *FirstLastAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *E-Mail *Tribal Affiliation *Survey Questions1. Is Anyone in the home pregnant? *YesNoPlease indicate how many weeks pregnant. *2. Are there any children in the home under the age of 18 years old? *YesNoPlease indicate the children's age. *3. Parents as Teachers is based on Family Well Being, Child Centered Development and Parent Child Interactions. Which of the following categories would be most beneficial to your family? *Child DevelopmentChild Development screeningSchool ReadinessResources and ReferralsMonthly parent and family group activities4. Do you have any developmental concerns about your child(ren)? *YesNoPlease explain the concern? *5. Parents as Teachers provides Home Visits twice a month (visits are via zoom or phone calls during Covid-19), would you be able to commit to these visits? *YesNo6. Parents as Teachers also offers monthly Group Connections where families and children can socialize while building on Child Development skills. Would you be interested in group connections? *YesNo7. Would you like to become part of Parents as Teachers? *YesNoSubmit
