• Enrollment Form

    Enrollment Form

  • Thank you for your interest in RCDC Parents as Teachers. This free program is designed to support early learning for all children and families. This program is grant funded which requires us to request the information below. The information you choose to share will be used to help your parent educator tailor home visits to meet the specific needs and interests of your family. All answers are confidential and optional to report. The program does not discriminate based on any information provided.

    Should you have any questions about the information being collected or have any technical problems with the enrollment, please call our office at: 620-275-0291

  • Parents as Teachers Enrollment forms:

  • Primary Caregiver Profile

  • Enrollment Date*
     / /
  • Is this a prenatal enrollment?*
  • Gender*
  • Single or multiple pregnancy:*
  • Doula Services:*
  • Frequency of prenatal vitamins (per week):*
  • High risk pregnancy?*
  • Pregnancy risks?:*
  • Exposure to/use neurotoxins:*
  • Neurotoxins:*
  • Planned birth location:*
  • Feeding plan:*
  • What is your relationship to the child(ren) being enrolled?*
  • Format: (000) 000-0000.
  • Cash Sources*
  • Non-Cash Sources:*
  • Are there residents living in the home that are not immediate family members?*
  • Employment Status*
  • Primary Caregiver Ethnicity:*
  • Primary Caregiver Race (check all that apply):*
  • Were you foreign born?*
  • Date entered the United States?*
     - -
  • Does the parent speak a language other than English at home?*
  • Education:*
  • Are you currently taking classes/enrolled in school or college?*
  • Start Date
     - -
  • Caregiver has seen a healthcare provider within the last 12 months:*
  • Recent Emergency Room Visits:*
  • Caregiver has a medical or developmental condition or diagnosis:*
  • Military Service:*
  • If yes, currently deployed?*

  • RCDC PAT strives to serve as many families as possible with home visits. Due to time constraints, there will always be less slots available for families who can only meet after 4pm than for families who have availability from 8am-4pm.  For these reasons, it is our program’s policy that we reserve slots from 4-6pm for families who both parents work outside of the home and whose work schedules do not allow them to be available prior to 4.
  • When is the best time for a personal visit?*
  • What are you hoping to get out of the Parents as Teachers program? (select all that apply)*
  • Household has a history of child abuse or neglect or has had interactions with child welfare services.*
  • Someone in the household has a history of substance abuse or needs substance abuse treatment.*
  • Someone in the household uses tobacco products in the home.*
  • Someone in the household has attained low student achievement or has a child with low student achievement.*
  • Household has a child with developmental delays or disabilities?*
  • Someone in the household is currently serving or formerly served in the US armed forces?*
  • Select the next set of forms:*

  • Secondary Caregiver Profile

  • Enrollment Date*
     / /
  • Gender*
  • Please select the Caregiver/Child/ren relationship:*
  • Is the Secondary Caregivers address the same as the Primary Caregiver's?*
  • Format: (000) 000-0000.
  • Cash Sources*
  • Non-Cash Sources:*
  • Employment Status*
  • Secondary Caregiver Ethnicity:*
  • Secondary Caregiver Race (check all that apply):*
  • Were you foreign born?*
  • Date entered the United States?*
     - -
  • Does the parent speak a language other than English at home?*
  • Education:*
  • Are you currently taking classes/enrolled in school or college?*
  • Start Date
     - -
  • Caregiver has seen a healthcare provider within the last 12 months:*
  • Recent Emergency Room Visits:*
  • Caregiver has a medical or developmental condition or diagnosis:*
  • Military Service:*
  • If yes, currently deployed?*
  • Select next set of forms:*

  • Linking Children to Secondary Caregiver

  • Secondary Caregiver should be:*

  • Child 1 Profile & Demographic

    Please fill out information for children 5 years and under in the child information areas and fill out the additional siblings area for older children.
  • Enrollment Date:*
     - -
  • Is Child 1 address the same as the Primary Caregiver?*
  • Gender:*
  • Child 1 Ethnicity:*
  • Child 1 Race (check all that apply):*
  • Any illness or complications during pregnancy or delivery?*
  • Any hospitalizations since birth?*
  • Any current medical conditions?*
  • Child 1 Insurance Status:*
  • Where does the child usually go for medical care?*
  • Does the child have a Dentist they see?*
  • Did the Child receive any amount of breast milk at age 6 months?*
  • If no, did the mother have a medical condition preventing her from breastfeeding?*
  • Is/was infant always placed to sleep on their back, without bed sharing or soft bedding, through 12 months of age?*
  • Does this child receive child care from a licensed child care provider?*
  • Enroll/Add 2nd Child?*
  • Update Demographics for a 2nd Child?*

  • Child 2 Profile & Demographic

  • Enrollment Date:*
     - -
  • Child 2 Gender:*
  • Child 2 Ethnicity:*
  • Child 2 Race (check all that apply):*
  • Any illness or complications during pregnancy or delivery?*
  • Any hospitalizations since birth?*
  • Any current medical conditions?*
  • Child 1 Insurance Status:*
  • Where does the child usually go for medical care?*
  • Does this Child have a Dentist they see?*
  • Did the Child receive any amount of breast milk at age 6 months?*
  • If no, did the mother have a medical condition preventing her from breastfeeding?*
  • Is/was infant always placed to sleep on their back, without bed sharing or soft bedding, through 12 months of age?*
  • Does this child receive child care from a licensed child care provider?*
  • Enroll/Add 3rd Child?*
  • Update Demographics for a 3rd Child?*

  • Child 3 Profile & Demographic

  • Enrollment Date:*
     - -
  • Child 3 Gender:*
  • Child 3 Ethnicity:*
  • Child 3 Race (check all that apply):*
  • Any illness or complications during pregnancy or delivery?*
  • Any hospitalizations since birth?*
  • Any current medical conditions?*
  • Child 1 Insurance Status:*
  • Where does the child usually go for medical care?*
  • Does this Child have a Dentist they see?*
  • Did the Child receive any amount of breast milk at age 6 months?*
  • If no, did the mother have a medical condition preventing her from breastfeeding?*
  • Is/was infant always placed to sleep on their back, without bed sharing or soft bedding, through 12 months of age?*
  • Does this child receive child care from a licensed child care provider?*
  • Enroll/Add 4th Child?*
  • Update Demographics for a 4th Child?*

  • Child 4 Profile & Demographic

  • Enrollment Date:*
     - -
  • Child 4 Gender:*
  • Child 4 Ethnicity:*
  • Child 4 Race (check all that apply):*
  • Any illness or complications during pregnancy or delivery?*
  • Any hospitalizations since birth?*
  • Any current medical conditions?*
  • Child 1 Insurance Status:*
  • Where does the child usually go for medical care?*
  • Does this Child have a Dentist they see?*
  • Did the Child receive any amount of breast milk at age 6 months?*
  • If no, did the mother have a medical condition preventing her from breastfeeding?*
  • Is/was infant always placed to sleep on their back, without bed sharing or soft bedding, through 12 months of age?*
  • Does this child receive child care from a licensed child care provider?*

  • Other Family information

  • Do you have any other children who are not enrolled in PAT (for example, older or school-age siblings)?
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  • Data Collection Consent Form

  • Please select 1:*
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  • Parents as Teachers Participation Agreement and Consent for Services

  • Please select 1:*
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  • Photo/Video Release

  • Please select 1:*
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  • Release of Information Consent Form

  • Please select the RCDC programs authorized to share information:*
  • Please check any other agencies or persons that you would like information to be shared with:
  • Please select 1:*
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  • MIECHV Program Evaluation & Data Sharing Consent

  • Parents as Teachers participates in the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program to evaluate and improve services.

    If you choose to participate, information about you and your family will be collected and securely submitted electronically to the appropriate Kansas state agency overseeing the MIECHV program and its data management contractor. Your information will be combined with other families and used only for reporting purposes.

    Your identity will be kept confidential. An individual ID number will be used instead of your name. Only authorized staff will have access to this information.

    This consent shall continue until my enrollment in the program is completed or discontinued. I understand that I may withdraw this consent at any time in writing.

  • Do you authorize the sharing of your family’s information as described above for MIECHV program requirements?*

  • Participation in the Parents as Teachers program through Russell Child Development Center is funded through the MIECHV program. Families who choose not to authorize data sharing are not eligible to participate in services.

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