DS9 Document EFTA01246758

f tlej.g ) . NEW/RETURNING ucrotuart STUDENTS RES I STRAT ION TO THE PARENTS OR GUARDIANS: NEW STUDENTS: Complete all non-shaded areas. RETURNING STUDENTS: Please review both sides for correctness of typed information shown below and co the a sh" side. if the information printed is incorrect. Please correct it by carefully and lightly crossing out the incorrect information and writing the correct Information above it. e..< TOO NT 'S LEGAL II (2) ALSO 010 it AS %.e t I 0101e-MONNIC On OF ESTI riel ) .' • O1 : i /qii (IS MALI VE MTN 1#412/ 024 Re' Lies • HO RESIDENT STATUS 0 O. FOREIGN EXCHANGE STUDENT 0 I.I. OUT•OF-COUNTY RESIDENT 0 2. OUT•OF•STATE AESIDENT Er; IN•COUNTY RESIDENT 12) GRAN UThl. ea melgArefa l reenta IMPACT Am SURVEY W APPLICABLE' (CHECK THE LET TER CODE FOR ONE CODE ONLY! 3 I on on IN Nan. Mitiliry Soma. 3 B ,..........,,,t. ..„,..z..... it .....t....: .at.zk...:: ,.. std.., viss. III) WS TICS CHILE SEEN ENTREE IN ANT PRESC1100L7 . •'Please Flot• I thachisrt (14 by tub program elisHite. AIN. Islitale she. ao +OHIO I *1 ON prelim yoat pile N Ilit 'engem! 0t. -CHAPTER I . 0 It MICRON PRE-11 ' 00 PRE-C. OISABILITIES 8 N. NON-SIPOTIO1210 DOW CAW E. PRE-1 EARLY INTURENTION __ _,.. 0. OTHER N. WAOSTART at. SUBSIDIZEO CHILD CA F SI Is (be **Mel e Desk WINO I YES Eil fo tagiSOVITANIVOrie&no if NAME Of SCROOt TR ERRING FACW tejLea4re it/t) 77. Ill CDT OR LOCATION E7:7a/4 4- - 016tel..eL—" • in OAT( OF LAST ATTENDANCE ,t-i /995 CRAW (2W. f 120) UST MIRK SCICOL ATT(1010 PALM BEACH COUNTY 6 2 /1 1)CL9 Zi e---• L2 OISE AMINO 93 - 96 ECtitWO) cl N la Ins yee NNW ets es *plinths let Pas of Ilgtoted Loch? asplicules Is memo with Ills RegIstrition Then) ill DS EI •1110 HEALTH SCREENINGS: RI) I gin Ferelnite let Thy dill le be gist. beta Hite/Hags. Tem tens mity be glees Intivilaally et In genes OK SODIUM It 10E. I give sem:idea ler my child Is panklpele in Il e swan Thestitle Preys* In le pent* bait! decay. IttenIssiee Is *Ill none toils Flt. NS Dm Bcr Il romexcloativp.; QmelatiewAvgtscatateratagefogswaya, MS ' hil tna Nervy is spoken it The bent, by 1St poem or Dwelt* / . CA_ cts-/- CM Mai 'engem Is spoken is St Hat by De Molt.' es_#,:s-/- RN OM el fury IMe (SIX Pintas CM I. Ii • wens,. Hese INA &IN. 'a" '. n. ' eh.? 0 ICS al* 2. coos me ousts' kr. I hen lasevae• Ginn inn. eniNiNil O ns El-tto 3. Cions us swam ant tie/wenn, ion,. • 'aorta,* itinst No This's? ORS EISO RR EFICE.11Sgtrang, t. .3.-.,1. nlir4::4!Xap it io. . Auss..y.ot:wiTicDc( ji. kait i:r., f.aultMrliwt!erk- . 14YY311 eir C4 II PAIrk)...rf,r).A S ' s im, •.,:ile)irf;ls. PT Acr.. tl lOe I I .I I ' lici • tiiii i.i i .1. .1 .. L (9! .41,1F1CA71,Th -.Q! ' hIE.11, .0. [ Iio :;;;;;•••:ni.'.! E LK , i' Lk', 4. 4Ll.. 5' (31 1 Cnr,1 00 CITE ITS/..The. I i rini2it 2: ; c...1 ..,..; (: ;Syr., ;O. ; , ...i.. 0,,q 'J.) N n)! ;iii , p, ,- ., . _:, . . _ ___ w„It I Theill TI1AT THE 11ONMATION GIVEN IS 11WE I AMB ACCUAATE TO 111( OM Of MT INOWLFOGE. • do dor.. O BSO 0636 REV. 4/95 CONFIDENTIAL FRONT MM08-M LICATA-000040 3501.135-014 Page I of 2 EFTA_00066381 EFTA01246758 U ." :riam I..1 vJ a, Gf I U U its*•• Her LAI LEGAL GUARDIAN If ANTI Oats Liam GUAAOIM HAW CUSTOM? to. tmo.d. 041 UITS O NO soattt TM Aosta CCO/PAtIONI Stan MON aWare7s."flra!:,:ik.W,?-1,4,'w.t,R1<,Thg, IN rAttt t rtnt.ta tent St. ...tot moon.. g. pla v. modem. I MR ASSVIOROt IS In "ME a Pmdzo MD ADDRESS 11002126.41 / /"/,J \ - Y WA ( l* e 74, M. moss. IP IS Oi A411141-74 14vAe .1 7 qe-46 -1-46 0---Auf leelig Amp,- 09-409617 Ilk 953- 1" 44 , 8-ws 0 No 0 YES 0 NO 0 lies 0 NO 0 YES 0) ° _ FIS PART t N o..1 is HAW I• Awn% yr/ I F DOCTOR ' I Ma •••14•4 say Ay ken yew ponesSo• ea vow Lwow •r •norrary Tonne PIO w••••••II HI NA ?..PIIA TESO N 16.Et PHONE MAINER lamHOSPITAL HOSP PREPIINVI eatt e/ 0.7- 9300 .7) NAMEMI OF CH:LOASO ▪ µ.wra Oho. it w• Stead b• aware 4 Non Alt Oa ATTENOMG NODE 1651 fNDExi D. I • MAL/ GflAD PO BIRTH DATE C‘0>brat'Aii CONFIDENTIAL MM08-M LICATA-000041 3501.135-014 Page 2 of 2 EFTA_00066382 EFTA01246759