Parents as Teachers Enrollment Form

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Parents as Teachers Enrollment Form

Providing services for families in USD 260 & 263

sdannels@usd263.org Switch account

Not shared

I am interested in receiving home visits. *

Yes

If yes, what time of day is best.

Morning

Afternoon

Evening

Clear selection

Please be more specific with what time is best for you and your child. We understand schedules may change. This gives us a general idea of what works best for your family.

Time

I am interested in enrolling my child (ages 3-5) into Wee Panther Pals (WPP) parent/child preschool.

Classes meet once a week for two hours and an adult attends class with their child. Small fee may apply.

Spots are designated for USD 260 families due to funding. However, if spots are available after enrollment USD 263 families may enroll.

Yes

I would like to receive emails regarding playgroups or parent workshops. *

Yes

Other (I work full time and would like to know about evening and weekend events)

Type your email here. *

Mother's/Guardians Information

Name *

Date of Birth *

Date

Race/Ethnicity *

Telephone Number (including area code) *

Father's/Guardian's Information

Name *

Date of Birth *

Date

Race/Ethnicity *

Telephone Number (including area code) *

Marital Status *

Address (must reside in the USD 260-263 boundaries) *

City & State *

Zip Code *

I resided in the following USD boundaries *

USD 260 (Derby)

USD 263 (Mulvane)

How did you hear about PAT? *

Are you or your spouse in the military? *

Yes

Child's Information

What is the name of the child or children that you would like to enroll in our program? *

What are the child(s) gender(s), race and date of birth(s) *

Do you have any developmental concerns with your child(ren)? *

What is the primary language spoken in the home? *

Are there any other children living in the home? *

Yes

If yes, please include the other children's names and ages here. *

I give permission for my child to be interviewed, videotaped, or photographed by the media or USD 260 student broadcast of publication for the radio, television, print story, or internet used to positively promote USD 260, its programs, services, staff, students and community. I grant and assign USD 260 the right to reproduce, copy, exhibit, publish, sell, or distribute such materials in which the aforementioned students appear. * Unless written notification is provided to Derby Public Schools Assistant Superintendent of Human Resources, USD 260 Administrative Center, 1550 E. Walnut Grove rd, Derby, Ks. 67037. A written confirmation will be provided to families that submit such a request.
Open Events: Please be aware that ensuring student privacy is NOT POSSIBLE during open events such as school or district-related meetings, assemblies, activities, performances and athletics where cameras are permitted. Parents, guardians, family members, and students are potentially taking and sharing photos and videos during these Open Events, even if not open to the general public. Images of your student could be in these photos and videos. By choosing to allow students to attend or participate in such activities and programs, parents/guardians agree to this condition. USD 260 will do its best to not share photos of students with photo opt-out forms taken at open events, but the district has no control over how those who take the photo or video choose to share the images.

If you have questions regarding the program please call (316)554-0110 or email jlewallen@usd260.com

I confirm that I have read and understand the statement above. Parents may also speak with PAT staff directly if you don't want photos shared on social media or for promotional purposes.

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