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TPS Enrollment Form
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Teen Parent Services Enrollment Form

Teen Parent Services Enrollment Form
Teen Parent Services Logo

Welcome to Teen Parent Services! Each year we are required by DHS Childcare Licensing to enroll your child in an Early Learning Center. If you have any questions about enrollment or this form, please contact Michelle Johnston 612.668.4703 or michelle.johnston@mpls.k12.mn.us. Teen Parent Services looks forward to supporting you as you earn credits towards your High School Diploma and graduate!

Teen Parent Services City Wide Social Worker: Kirstin Johnson-Nixon 612.669.0945 Kirstin.Johnson@mpls.k12.mn.us
Teen Parent Services Enrollment Coordinator: Michelle Johnston 612.668.4703 Michelle.Johnston@mpls.k12.mn.us

Teen Parent Services: 612.668.4703 tps@mpls.k12.mn.us

Student Parent's Information
Student Parent's First Name 
Student Parent's Last Name 
What Minneapolis School do you attend? 
Student Parent's ID # 
Birth Date 
Address 
City 
Zip  
(XXX)XXX-XXXX
Student Parent's Phone Number  
Can you receive Texts?
Email 
Student Parent's Race (check all that apply):






If other, please specify 
Student Parent's Ethnicity (check one)

Student Parent's Primary Language



If other, please specify 
Child's Information
Child's First Name 
Child's Last Name: 
Child's Birth date 
Child's Sex
Child's Race (check all that apply):






If other, please specify 
Child's Ethnicity

Child's Primary Language



Child's Information
If other, please specify 
Does your child have any of the following health conditions? (check box)







If other, please specify 
Any food or environment allergies or food your child cannot eat or be exposed to? 
Children under 12 months:
My child uses:


We provide Similac Advance. You only need to answer this question if you use a different formula.
These formulas will need to be provided by you or with a Doctor's Note:



If other, please specify 
My child has Medical Insurance:
If yes, which Medical Insurance Provider/Carrier? 
Health Care Information (write NONE if you do not have one):
Health Clinic Name 
Health Clinic Address 
Health Clinic Phone 
Dental Care Information (write NONE if you do not have one):
Dental Clinic Name 
Dental Clinic Address 
Dental Clinic Phone 
Emergency Treatment Information
I give permission to TPS to make whatever emergency measures as judged necessary for the care and protection of my child while under the supervision of the Early Learning Center.
In case of a medical emergency, my hospital preference for my child is: 
Emergency Contact/Authorized Pickup (REQUIRED). Childcare Licensing requires 2 contacts. TPS has my permission to contact the following people to pick up my child or if I am unavailable:
First and Last Name Contact #1: 
Address: 
City: 
Zip: 
Phone: 
Relationship to you: 
First and Last Name Contact #2: 
Address: 
City: 
Zip: 
Phone: 
Relationship to you: 
I give permission for the staff at TPS...
Diaper Wipes: to use diaper wipes on my child, when needed.

Diaper Ointment (like Vaseline or Aquaphor): to use over the counter diaper ointment on my child, when needed.

Pictures/Videos: to hang up around the Early Learning Center and to be shown in the classroom.

Neighborhood Walks: to leave the Center's grounds & property under the supervision of a staff member for neighborhood walks.

Sunscreen: to apply sunscreen to my child upon their discretion. I recognize that the Center is not liable for my child getting sunburned.

Bug Spray: to apply bug spray to my child upon their discretion. I recognize that the Center is not liable for my child getting bug bites.

Do you currently have a MVNA Nurse/Case Worker?

If yes, name of MVNA Nurse/Case Worker? 
Teen Parent Services contracts with, and is primarily funded by, Hennepin County. Childcare services funded by the County are contingent on the Student Parent being in attendance. Teen Parent Services provides childcare for Student Parents ONLY on days that Student Parents are attending school and working toward a high school diploma. If a child attends childcare, but the Student Parent is not in school, Teen Parent Services will issue one reminder only. If it happens a second time: 1. Childcare services will end. 2. Hennepin County will be notified. Hennepin County Child Care Assistance Rules state that a Student Parent may be required to reimburse Hennepin County for the cost of childcare used on days that the Student Parent did not attend school.
Student Parent Attendance Agreement
Student Parent Electronic Signature 
Type your Signature.

* denotes a required field