Mehlville Parents as Teachers Enrollment Record
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Primary Parent/Guardian Information #1
This section to be completed by primary parent/guardian of the child(ren).
1. Last name *
2. First Name *
3.  Date of Birth
MM
/
DD
/
YYYY
4.  Street Address *
5.  City *
6.  State *
7.  ZIP Code *
8.  Telephone Number
9.  Email Address
10.  Marital Status
Clear selection
11.  Relationship to Child(ren) Enrolling *
12. Ethnicity
13. Primary Language Spoken in the Home *
14. Secondary Language Spoken in the Home
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