Lee's Little Learners - Home Visit Request Form

Items denoted with a red asterisk * are required.

Home Visit Request Form
Please submit the following information. Joni Johnston will contact you to schedule your home visit.

* Name

First Name

Last Name

First Name / Last Name

Email Address

School Name

* Phone Number

- -

(XXX)-XXX-XXXX

* Ages of children in the home

Birth to age 1 - Infant
Age 1 to age 3 - toddler
Age 4 - preschool
Age 5 - kindergarten

* Please list the times that you are available for a home visitor to come to your home.

Additional comments/questions