Hancock Parents As Teachers

Mother's First and Last Name ***

Father's First and Last Name **

Address *

City 

State 

Zip Code 

Phone 1 

Phone 2 

Email Address 

Are you a first-time parent? YesNo*

Race/Ethnicity 

Language spoken 

Insurance PrivateMedicaid

Child 1 First and Last Name 

Child 1 Birthdate 

Child 1 Gender BoyGirl

Child 1 Ethnicity 

Developmental Concerns 

 

Child 2 First and Last Name 

Child 2 Birthdate 

Child 2 Gender BoyGirl

Child 2 Ethnicity 

Developmental Concerns 

Child 3 First and Last Name 

Child 3 Birthdate 

Child 3 Gender BoyGirl

Child 3 Ethnicity 

Developmental Concerns 

School District **Hancock 

What are the best times and days for a personal visit?  (Check all that apply)

Morning   Afternoon   Evening   Mon   Tues   Wed   Thurs   Fri   Sat

Do all parents/guardians work outside the home?  Yes  No

Does your child attend preschool or child care?  If so, where and since what age?

 

Security Measure