Online Application for the Pregnancy to Age Three (P-3) Home Visiting Program

The P-3 program is a free service provided to families.  We are currently enrolling families that either live in the service area or have a sibling enrolled at one of our campuses or a sibling that is an alumni.

Only one child per application, please.

PLEASE FILL IN ALL INFORMATION REQUESTED

 

Are you pregnant and wish to enroll before the baby is born?

Expected date of delivery

  

If your baby has already been born, please give the following information:

Child's full name

Child's date of birth

Home phone

Child's primary address

City , State Zip

Does the child live in the service area (see image below)?

 
ServiceArea 

Parent/Guardian Information

Mother

Mother's name

Mother's Home phone

Mother's employer

Mother's Work phone

Mother's email

Mother's Cell phone

 

Father

Father's name

Father's Home phone

Father's employer

Father's Work phone

Father's email

Father's Cell phone

 

Sibling Information

Does the child have a sibling who is 1) enrolled at any of our campuses, or 2) an alumni?

If yes, please give name(s) of sibling(s)

Year last enrolled

Number of Years enrolled

 

Parents and/or Guardian's Language

Would you prefer to have a Parent Educator who is fluent in Spanish?

Does the child hear, understand or speak a language other than English?

If yes, what language(s)?

How did you hear about the PAT program?

 

Additional information?

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