Enrollment Form

To begin the enrollment processes with the Parents as Teachers program, please fill out the form below and someone from our staff will contact you shortly. If you have any further questions prior to enrolling, contact Dorian Traube at traube@usc.edu

Personal information

First name

Last name

Your date of birth

Relationship to Child

Your ethnicity (Optional)

Your child's name

Your child's age

Contact information

Home phone (Required)

Work phone

Mobile phone

Email address (Required)

Address

City

State

Zipcode

Program Preferences

Which days are best to reach you by phone?

Do you have a time preference on those days?

What is your preference for your weekly online appointment?
Do you have a time preference for your appointment?

How did you hear about us?

I am interested in the Parents as Teachers program and give permission for a representative of USC Telehealth to contact me regarding more information and/or enrollment.
The Parents as Teachers program is delivered through USC Telehealth videoconferencing technology. USC Telehealth does not provide crisis or emergency services. Please call 911 for any emergencies.
I consent to allowing USC Telehealth to inform the LA Best Babies Network if I enroll in Parents as Teachers @ USC Telehealth. This will ensure that I am not approached multiple times about enrolling in a home visitation program.



©2017 Parents as Teachers National Center, Inc.