Parents as Teachers Application Question Title * 1. Child's legal first name Question Title * 2. Child's legal last name Question Title * 3. Gender Male Female Unspecified Question Title * 4. Date of birth Month/day/year Date Question Title * 5. Street address Name Address Address 2 City/Town State/Province ZIP/Postal Code Question Title * 6. Please select the ethnic group that best describes you Asian-American African-American Hispanic Multi-Racial Native-American White Other (please specify) Question Title * 7. Language spoken in your home? English Spanish Turkish Arabic Swahili Chinese Kinyerwanda Other (please specify) Question Title * 8. Child's t-shirt size 0-3 months 3-6 months 6-9 months 12 months 18 months 24 months Youth XS (2-4) Youth S (6-8) Youth M (10-12_ Youth L (14-16) Question Title * 9. Primary guardian's t-shirt size XS S M L XL 2X 3X 4X 5X Question Title * 10. First name of primary guardian Question Title * 11. Last name of primary guardian Question Title * 12. Relationship to child Mother Father Other (please specify) Question Title * 13. Email address Question Title * 14. Primary phone Question Title * 15. Alternate phone Question Title * 16. Guardian #2 first name (Guardian #2 is optional) Question Title * 17. Guardian #2 last name Question Title * 18. Relationship to child Father Mother Other (please specify) Question Title * 19. Email address Question Title * 20. Primary phone Question Title * 21. Secondary phone Question Title * 22. Household size (please include anyone living in the home) Question Title * 23. Which amount describes your annual income? Under $25,000 $25,001-$42,000 $42,001-$60,000 $60,001-$79,000 $79,001 and above Question Title * 24. Do any of these describe your family? Foster care Kinship care Homeless A refugee None of the above Question Title * 25. Please list any other children UNDER the age of 5 (first and last name) living in the home and their date of birth: Question Title * 26. Upload birth certificate here If you have issues uploading or need assistance getting a birth certificate, email us at reachingforreadiness@preschoolpromise.org PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File If you have issues uploading or need assistance getting a birth certificate, email us at reachingforreadiness@preschoolpromise.org Done