Application for Pregnancy-to-age-3 (P-3) Home-Visiting Program

Lumin’s P-3 Home-Visiting Program is a free service provided to families, there is no tuition charged.

Currently enrolling families that live in Zip Codes: 75210, 75223, 75227, 75215, 75228

Today's Date*

Answer required for "Today's Date"

Is your Child less than 26 months old? *

Answer required for "Is your Child less than 26 months old? "

Yes

No (If no, please be aware that, since our program only goes through 36 months, we usually do not accept children into the program who are over 26 months)

Child's Date of Birth or Due Date*

Answer required for "Child's Date of Birth or Due Date"

Child's full name: (If child has not yet been born, please put “prenatal”)*

Answer required for "Child's full name: (If child has not yet been born, please put “prenatal”)"

Child's primary address:*

Answer required for "Child's primary address:"

Race:*

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First Parents name:

Answer required for "First Parents name:"

Phone:*

Number Required

Email:*

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2nd parents name if applicable

Answer required for "2nd parents name if applicable"

Phone:

Number Required

Email:

Answer required for "Email:"

Parents/Guardians Language: Primary language used in your home:*

Answer required for "Parents/Guardians Language: Primary language used in your home:"

Are you comfortable communicating in English?*

Answer required for "Are you comfortable communicating in English?"

Yes

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

Answer required for "Would you prefer to have a Parent Educator who is fluent in Spanish?"

Yes

What are you hoping to get out of this program? (Select all that apply)*

Answer required for "What are you hoping to get out of this program? (Select all that apply)"

Learn about child development and parenting

Support for educational attainment and/or employment

Support/information on family planning

Support for maternal health and well-being

Increase social support

Support for obtaining healthcare and /or health insurance

Support for meeting economic and/or housing needs

Support for mental health

Other:

How did you hear about the P-3 Program?*

Answer required for "How did you hear about the P-3 Program?"

Please fix the highlighted areas below before submitting.

Application for Pregnancy-to-age-3 (P-3) Home-Visiting Program