State Superintendent of Public Instruction

OKLAHOMA STATE DEPARTMENT OF EDUCATION

 

OKLAHOMA PARENTS AS TEACHERS (OPAT)

RECRUITMENT/ENROLLMENT RECORD

 

Child’s name:   M              F      Phone: 

Date of Birth:   Child’s Due Date:  

Child's Ethnicity (optional):  White   African American   Native American   Hispanic/Latino   Asian American  Multi   Other

Child’s Address:     Zip:  

School Where Child Will Attend:     How Did You Hear About PAT?:  

 

Would you like your monthly newsletter sent via Email  or US Mail

 

Family Information:

Marital status (optional):        Married           Separated          Single          Divorce       Widowed

                                                    Mother                                                         Father 

Name:                                                                           

Birthdate  (optional):                                

Last grade in school:                                

Work (full/part):                                       

E-mail address:                                        

Best time of day for a visit:  8:00 a.m. - 4:00 p.m.  After 4:00 p.m. (Limited evening schedule)

Mother's Ethnicity (optional):  White  African American  Native American  Hispanic/Latino  Asian American   Multi  Other

 

Father's Ethnicity (optional):   White  African American   Native American  Hispanic/Latino Asian American   Multi  Other

Name and phone number of person to contact if unable to contact parent: 

Language used most frequently in home: 

Does anyone in the family have a disability or delay?  Describe:  

Siblings living in the home              M F  Age:   Name/Birthday: 

                                                    M F  Age:   Name/Birthday: 

                                                    M F   Age:  Name/Birthday: 

 

Residents in home other than        M F  Age:  Relationship to child: 

                                                  M F  Age:  Relationship to child: 

                                                   M F  Age:  Relationship to child: 

Child Information:

Baby’s birth weight:  lbs. oz.   How long did infant stay in hospital after delivery:

Any illness or complications during pregnancy or delivery?  

Has the child been hospitalized since birth?  If yes, please explain.

Name(s) of child’s medical/service provider(s):  

Date of last exam by physician:  

Name and address of regular childcare provider other than parent:     

     Child Care Provider Phone:  

Additional comments or information (attach sheet if necessary):  

Are you currently receiving assistance from any of the following:

WIC     Housing Authority      Food Stamps    TANF  (Temporary Aid to Needy Families) 

Medicaid Card      Other Services (Counseling, etc.)

 

When you submit your enrollment, it will automatically be sent to jamesda@tulsaschools.org.