EFTA Document EFTA01709700

SEX RACIAL/ETHNIC GROUP 0 Hispanic t i.cAlhae, Not Hispanic 0 American Indian/Native Alaskan 0 Black, Not Hispanic 0 Asian/Pacific Islander Sit • Legal ADDRESS: (usepencil in this e, until final.) PHONE NUMBER: (optional) Verified by Birth Certificate: triCirs If Not. What Type Verification? NAME OF PARENTIS) OR L GAL QUARDIAN OR OTHER RESPONSIBLE ADULT AT HOME: G OA BIRTHPLA• P CURRE Name Street City 2, qfjyst Entes h is District yes,/ Withdrawal Date Withdrawal Date Withdrawal Date Gradig $ Cre4 School . Grede. K G,..51. Glii i School Year. 19. 23-- -19 School year. 19 gq .19 (15 School Year 19 -19 School Year: 19 -19 /7 School Year. 19 Cl rl •19 A__ -9.g.-- Days Present: / & Bit Days Abyt i if Days Present 1641 Days Absent: 1 Days /Present' /625' Days Absent: /40 Dan Prieg:9 Days Abs. Days Prose 16 : fl Days Absent Subject Teacher Mark Subject Teacher Mark Subject Teacher Mark Subject Te er Subject Tea her rk MATHEMATICS MATHEMATICS MATHEMATICS MATHEMATICS MATHEMATICS i READING lk READING READING LANGUAGE READING LANGUAGE READING LANGUAGE LANGUAGE SPELLING SPELLING g S"ELLING SPILLING _LANGUAGE SPELLING HANDWRITING HANDWRITING iS HANDWRITING + HANDWRITING HANDWRITING SOCIAL STUDIES SOCIAL STUDIES t2 SOCIAL STUDIES V STUDIES SCIENCE end SCIENCE end V _SOCIAL SCIENCE end vel l— _SOCIALSTUDIES SCIENCE end HEALTH SCIENCE and KAI TH A , HEALTH HEALTH HEALTH BEHAVIOR COOS AVERAGE 3 BEHAVIOR CODE AVERAGE 3 BEHAVIOR CODE AVFRAGE °it BEHAVIOR CODE 5 BEHAVIOR CODE AVERAGE 3-- AVERAGE O cc Indicate. Promote (PI Patent (Et) Summer School 15$) p Irdicate. Promote IP) Retain (RI Summer Schaol1551 p Indicate: Promote (PI Retain IR) 11pierner School (551 P Indicate: Retain (RI Summer School (SS/ Indicate Promote (P1 Retain IR) Summer Scnocd (551 f ) School Grade. School. Grade: 4:E (...) Gracie: 5 School. Guide. School. Grade. Oa CC O School Year 19- -19 I li School Year 19 .19 _ St Year 19 •19 — School year 19 -19 _ School Year 19 •19 0 LI U IL1 u.i CC CC C D Present: an i 67n 0in Absent: 02 4/ Days Poison! Days Absent: Days Present Days Absent: Days Present. Days Absent: Days Present: Days Absent: o I— z Subject Teacher Subject Teacher Mark Subject Teacher Mark Subset Teacher Mark Subject Teacher Man Z m„ MATHEMATICS MATHEMATICS MATHEMATICS MATHEM_ATICS MATHEMATICS W READING READING READING READING READING "O LANGUAGE LANGUAGE LANGUAGE LANGUAGE LANGUAGE 4 1-li SPELLING irk SPELL IND SPELLING SPEI LING SPEI 1.1110 i HAND1M3ITING HANDWRITING HANDWRITING HANDWRITING HANDWRITING CC cE SOOAI STUDIES SOCIAL STUDIES SOCIAL STUDIES SOCIAL STUDIES SOCIAL STUDIES to Lu , Q. )- •,_, SCIENCE and REALTY SCIENCE and HEALTH SCIENCE and HEALTH SCIENCE and HEALTH SCIENCE and HEALTH ...Er a -.a 0 fg, I la,,. BEHAVIOR CODE AVERAGE 1/4-.3 BEHAVIOR CODE AVERAGE BEHAVIOR CODE AVERAGE BEHAVIOR CODE AVERAGE BEHAVIOR CODE AVERAGE —I L7 K la • .e, _ _ Irvikate '—^•• net ..p Indicate: Promote (P) - .-. Indicate: Promote (P) Retain IR) --. Indicate: Promote (PI Retain Ifll ciiismai School (SSI Indicate: Promote (P) Retain IR) Summer &tool (SS) EFTA01709700 SECTION 2 SECTION 3 CONSECUTIVE SCHOOLS ATTENDED CHECKLIST OF CUMULATIVE DATA School/Address Date Enrolled Date Withdrawn Signatat Sending Senn3l* Og% TRANSCRIPTS SENT School/Address Dale Sent Sivelure Sending School' • The principal or designee of the sending school will sign to indicate the records are in compliance with stated requirements at the time they are sent. Contents of the Cumulative Folder should be arranged in the folio% order. Date' 9/43 4/0 5/ 47.c. Lion ELEMENTARY 4/1,4/W 15.Kindergarten Checklist Purge after 6th gi 16.PREP (SIR) folder Purge after 6th gi 17.Communications Skills Record Purge after 8th gi 18,Mathematics Record Purge after 8th gi 19.Chapter I Purge after 8th gi SECONDARY 20.Honors and Activities 21.Work Experience 22.Driver Education Certificate 1.Florida Permanent Record Card - Category A K-8 2.Florida Permanent Record Card - Category A 9-12 3.Special Characteristics Card 4.Notice of Psychological Evaluation staple back of Special Characteristics Card 5.Registration Forms - most recent on top 6.Cumulative Health Record- Immunizations, E Certificate and Physical Examination staple( side 7.Other legal information, such as court order, davits and correspondence from comm. agencies 8.Standardized Test Data Card 9.State Student Assessment Test Record 10.Special Education Information (Staffing, chological, placements, etc.) 11.Suspension letters/discipline record 12.Teacher/Counselor comments (behavioral servation, anecodotal records) 13.ESOL Student Reporting Form and ESOL Student Record 14.Student Progression/Summer School Info! • The individual responsible for the introduction of each item will place in' and date by that Item In ink. P8513 1018 (New 6/85) EFTA01709701 Pis Year: 2003 Grade: 10 School Coder Optional Code: School Copy Your Scores Ranges -- Verbal 52 44 U Math 52 Scores wthio these rarges can be mitered b you 80 20 tso Zo eo Men® ion lelen mem um nelertne =N. en 48 56 16 44 Writing Skills 40 Percentiles last Sff veto Review Your Answers Ask for your test book back so you can see the questions. ▪ tiro o Wed I/ WM& O EAR m Nam n inn ino Oen Nth Mast& NIA hem S teno a • RN I Mir ■ anis ammo Ma sand wen min 75% a when.. 200 Ye., voted hose( two- 70% or onalemo0es Nab Dame SAT Nadal SAT I Math SAT II: Writing Test 800 200 US 200 BU) min Sone lin we now mai stn inn one sennend nen men ma 480 580 480 580 Wllal inicany yea amass 'err U the questa:Ai in lour fest took laiSSI Yeitiv Fan a alit Wei ot) ao • in I Rothe • V Sy C a AS/ A A 0 ti —ILI 0 h A n Mfr.% Steward itt a NIL a Aro_ a GO__ Rat trAnn._ EDia Amy_ 0 itig; , AM I / 0 AAA Ill AcmGeo 11 Ili mArtn 2 I A m Ma la Carman'. 11 0 A m rua o enew to i h NE Tr A of ri Arm Quantlaate Caperierrie 88 CA Pi Na • SehAlg “ A I Pi OM fi at • Ann o / • o•• 24 I A m Al; 25 if S Arm rn 27 • • m Anti 044 m No IF -117ar re h Geo si C e ii Alg A • - WGeo Yoe araered arra* se Sc rail peen sed AMIN RIM% Yw anmeied eActreaN a7 q.esten(s) end mpruvinc Sentences Impronn; Paislants „M r e—I E E W E o E K Al e_ _72_1_ A m C __E4 D A es 2 05_ _AD 1B 0_ 13 27 c o rn 28 0 B 29_A_ m O. E A tn e. A  m 33 E ta t., 34 5 c op me 38 37 :At A l B e: 38 D A in 39 F B in YC° nvitrad C000Gfl 12 Of 39 weing eons mcatiou aid tamed 12 Vidal . . 2 of s annexe:4K of ya medisp mestons Af 7 lard quesions VD/ Quilled 0 oJesbat(s,. INMSQT National Merit Scholarship Corporation (NMSCI Programs Selection Index 144 Percentile 48 ttatyMit i oilman The Schram Wei s the sun of hied witid, Hoak ad MU} Jai scorn NESE an h SArcem Man as at Mal same or em t9 gas wants Me ago its scheesho armee (see revise). •TM a Manta n teat le year Select.oe index means you do sd neat entry requirements let %I.IS.7.'s %OS provarns See your re Henan t000taf Minn below isa 1.0e/Mar infer. Males en leg 'Wert. 1.6. Entre Requirements Beni 4 Soma* you prA041 owns Aux ANA I ItiLd Ada% YE 2110•01004 1•00012 ASS ensally. MO lima te ant si oldest 12: 4 0.S. ISIS YES B b les.. 0 ge ahes' c end &Moroi collets xi 2C•6 or nor take ma PSATM•050T ',sin in milINN IOW ovnice year) 01 .earl) wean *Dina*, $2 le ...nor warm% Your Educational Plans Dade Average C College Major PrIena4011Y Win Photorapis Wanton tow 6 selimialed CleaCeigellawl: Itycholegy miler 1,44y IIVITIOM !MI Ammar abet and swore ma patelital I ,nvo/ved I. normal and abnormal Inotnygs. %tags. and Seigel Students 'toy.** Batt ana t. acmes. d beNmot erste learning psychelOg.cal fads. rnetheal. riot Pies end areal' irat.got fl out In•Madeeli end 'rouge EFTA01709702 Sincerely. THE SCHOOL DISTRICT OF PALM BEACH COUNTY 1997-1998 END-OF-YEAR REPORT CARD INSERT for GRADES 1-5 4 Grade Dear Parent(s)/Guardian(s), In a continuing effort to keep you informed, this report card insert is being provided to notify you of your child's progress toward meeting the school district's desired levels of performance in reading, writing, and mathematics. Your child's end-of-year performance level in reading, writing, and mathematics is identified below. READING InPf ING (COMPOSITION) MATHEMATICS At or above grade level bon At or above grade level Ra<t or above grade level El Below grade level* I- 1 Below grade level* El Below grade level' 'If Below grade level has been indicated for reading, writing, and/or mathematics, you will be asked to participate in the development of a plan to improve your child's academic performance. This plan will be developed at the beginning of the 1998-1999 school year. Teacher PBSD 1674 (NEW 5/15/98) White/Cumulative Folder Yellow/Report Card EFTA01709703 No= Ws' 2003 Brandi: 10 School Code: Optional Code: =nom copy Your Scores Percentiles What SAT Ranges Can 'L i You Expect? Answers Review Your Ask for your test book back so you can sec the questions. KAI • COM:l o WOW t • fay rn t lied AI2 feitrn Ara keno Get Goren Scoring Edna se- PUJEl POW • ISM KNOX N am mars ewe ems ailment - INN IA PONA ills Mel IMP tee Steads • VMS la POPP • Wee neon le WO 11-44 Co LOOT TOWS Ont. xi Iota! "..• Lir •••, ;IC 11,1 Math 52 Writing Skills 40 AS 56 41 51 36 44 'Ow aporef higwr pi, 76%.. »rowan 5014 Yea seem nee. mon 70% os meranowo 50% You sated hytl.,Aiwa 12% et wiesseenes. 800 SAY I Verbal SAT I Math SAT II: Witty Test NINO MMII MINI I= == =WI Non me -- 300 600 AC qui seStt Mebane rare a sto beef co e eery When Snag pa earn refer to the pastors n your test book 2$ Sentence 2$ A_Ic • Coos ar up, bake $ C Ar_c_sc_oe D t h A 41 • C m sn oi• nco * Ste .Th eac sEnt sc ow. C A in You oramd aura at du total caution ad rad n Pato 1Ld 1i autritalito 14 04 n rnedllot rain _d_14 bled Thad! You witted o sueston(S. Ms ironed. innate:0c 20 quisteits) and D C h Gee 1 m orth r d n it IL_mnti__ 11 11 C I h any U tAmAle IS C s7 M Am li _A _ ft A I Is AM II D A h All X A C in GOO ii p AS (I hh OPP AIII It C V • Ant . 0 .V &Geo zi mc nLa rn Al Aic al lite Am n AI men 22 CAM Nth is 0 1 mole n o i m Art 3; Aflame 3i CST Mg  Act h liho sontad correct at do* man quagga and aerial 24 pitta 14 al it easy qudans 7 II 13 rrediun quesbom 3 of TO had qt.:sacra You EMS 2 pretWI(t), Yea roved incorreCtit 14 asiectionth anf Iasi 3 pings). Improve Your Skills lie skit Jared are based on or the test and epresint those that con hire the nest dome to improve with ern work. Fellow the suggcstors to mime in each area. ■ UnderslaidicEp main ideas in a rending passage How to improve: Read the WWI) passage caretsny and try to deecrene trio author's oral message. oractice insang distinctions between he maw Idea and suaporind detellS- See questons 14, St, 22. • Comparing and contrasting Ideas presented in two passages New to Improve: Pose sideoriaa that take ooposeg news Or an !Slue. Look 'or d tteronses and alreileaties In Iona, poet 0' Wen, and main idea. See OUCS1011% 41, 50, 52. • Applying Ideas presented M a reading passage How to improve: When you read, try to deter- (Ono Ina &UMW Werra era assumptions sea Men bank abbot how Mow might IIPC4Y A new srtuatons. See questons 41. 42. SO III Recognizing patterns and equetelent forms How to IMptiern Iry recognizing a pattern by COMO!, MI5 a siewer best 'Ty mooting Or rearranging trie given eawessiors in a Marra torn See questions 24, 27. clertifyirg entence Errtrs Improving Sentences e5C3:04/S ‘ rt,CXY I D E . ; D a Ei rri m Et  m 6 ▪ B E 7 5 E m 0 0 / is; g A EW /  WI A F l C  m 13 t  in IS D E E ie . 17 8 E W B *Cr c F E A a _tt_x_ A m 23 II Ca N ed_ to 0 0 rn 29 Atm 3Ati _q1_E Am _it_ A_✓ m 73 E A m se e o • a N B Pallgt3014 • t A en 37. A IS . 30 . D Am 39 E B m Ycu ductal cove:1012 of 30 WangSUS (22SIJOIS aid earned 12 rent[ 2 of • easy quietens ._ 10 0(23 medium rpestimu o of 7_ 1.3td queelons ree earned 0 quetton(p. YEu arunztd incerrecrhi? %molts) and led 7 /WHO INMSQT National Merit Scholarship Corporation INIASCi Programs Selection Index 144 " Percentile 48 MSS OW pithililibl WA selotteeel eswe %SUES Wait the cod MI C Ind Sint dar S mat Mate Ma es en serum of eat 13 at gents viho mho is 33301010 Mom (see rc000l• -Ma .. in tI M1 to yore Seradlern 'now you do not meet tan, morreentMs to. NV$Cr. AOC ercgramo Sat vrad nODOntes to enter ns below and WIN, mne mean on the nesse Ada Entry RequInsmenta PoHoil is ntarronoo leo prated on yes away sheet Ful-bne bott toed Cant eta View aegis eon Atm aid amt Wane r cash. zees Yeas to to gene 03des1-17: US avow* YES NOTE —ST,Tdare who will as awing high whoa and mitring cozen m 3021 or late mutt ten. the PSAHMISIST awn m tree INS year I suer year: re" grapes a throvell 12 Wemo• NIASC poppet Your Educational Plans Brats Average C Collop kW Posen Career Pheleirateshes Inalatbn tett a tilt. teed otescoption: Psycnolow rotors eddy hunt% awl SION, holtanor and Waled the pregite• involand o normal 04 Maroon& Marta twtlrgt. end saws Students istnatil Heir LAMM' punts d 1Wheteer while learnMo illWM1001Cal WS. menace. primates all 'Witte!, Millen About Adrvidualt all groups Associated SKIN. Ora ell rime communaatoe. Inge! mane ReCCenmentled High SCITOW Co..,.. En 'Cl. emarwe rat/omelet 3. v twiny 3. Meaty social Otalist 2. hoots conpaga 3, and computer science I Other Illajors to Consider Antnraporegy. Gore...rely. Seto work Sot OM, brach Estnecishoudeloos. Coons medicine. urban street and womana studies Carters: The undevaouste nabor it ;mythology an lad le Mt. as a dwnseer retn ernanairtrons Inn counsel yore, Rota. me howats. or emus or Sahel abusers It ran ad te onalehrasesicsne sentence ' cans e mentsl health w wool an. Work NOM IMO leacher - • <L,., -'n terra eerier with slats Or more tames, with the ca-wantons •1:1C mush indices doling wit .02stirWas0 written Engirt; h Welk with modal Pee/dation or • emotion& dilaNtitiet it is ono See questions 5, 7,9. '• mod preparation tor Naar study ire's l a w, timslorw. social • Understanding the structure of 1.0 . law putrid lawn strelon. sentences that relate to the arts • How lo krprorre: Focus on hove sconeCithp said es well as on what IS SSA. Read articles in no...editors and rnageenos seen tic ens 30 that you wi l reel more com'orleble with 0C30 aublOcla Seel elUe.3:10413 14,:0. EFTA01709704 THE SCHOOL DISTRICT OF STUDENT NUMBER: 600L 0 ,1 -V 0 -.Nxi I L ,9NEW/RETURNING PALM BEACH COUNTY STUDENTS VERIFICATION FOR NEW/RETURNING STUDENTS: TO THE PARENTS OR GUARDIANS: NEW STUDENTS: Complete all ron-shaded areas on bcth sides of form RETURNING STUDENTS: Please review both lidos for correctness of typed information. If the information printed is into rest, please correct it by carefully and lightly crossing out the incorrect information and writing the correct information above it. REGISTRATION ISTR ICFIR: TNBR: -. 8/12/98 HARM: 507 .•', 10 STUDENT'S LEGAL NAME Illllllllf I_ / (21 ALSO KNOWN AS ILL LOCAL AD IA MAILING ADDRESS LOXAHATCHEE FL 33470 U)w No. SIAM RANI AlT .16 t'ATT ZIP ICCF T.TV ,,,,,, Z• COPE ILL STUDENT'S SECT A: siCuR,Tr NO. (OPTIONAL/ 16) HOME PHONE ND. 01 I 9 8 SEX Er K TEAP-E HALE AN I RACE W arA NLZ IAINsurTivi e`"‘ NON- H.SPANIC I A ASIAN OR 9 H HISPANIC I tHISPANIC I W NOV-HISPANIC 9 M ItALTJ.ACIAL 151 DATE OE BIRTH Now,. Oar WA* 001 PLACE Of BIRTH • US Cry VIAPE Cale. III) RESIDENT STATUS 3 9 0 FOREIGN EXCHANGE S- UDINT 0 I. OUT-DE -COUNTY RESIDENT I 2. OUT-OF-STATE I 3. IN-COUNT, RESIDENT AESIDtNT (12) ENTRY DATE INTO USA 1131 IEDERAL YES YES I YES I IIS MT, IMPACT Mc SURVEY I NO A. THE STUDENT I NO B. THE STDOEN' 9 II0 C. THE PARENT I NO D THE PARENT I NO L. THE PARENT II WS, RESIDES (N RESIDES IN IS EMPLOYED IS EMPLOYED is IN THE IS THE PARENT AIR FORCE FEDERAL LOW RENT ON FEDERAL CN I3* UNIFORMED UN ACTIVE I ARMY PROPERTY. HOUSING. PROPERTY RENT NCUSING SCATIGES Of DUTY? I 9 COAST LOCATED IN LOCATED IN TH! UNITED YES 9 GUARD PALM BEACH COUNT,. PALM BEACH COUNTY. STATES. NO I MARINES 9 NATIONAL GUARD I NAVY O41 NAS THIS CHILD BUN ENROLLED IN ANT PRESCHOOL' N C. CHAPTER I U. PRE-K DISABILITIES I E PENH EARLY INTERVENTION (PLEASE PLACE A MERRIAM I mix 81 EACH PROGRAM WITH AN ASTERiSX I */ TO( PROGRAM YOUR CHILD I H. HEADSTART I M MIGRANT PRE-K I N NON-SURSIDIZEO CHILD CARE ATTENDEE. ALSO. INDICATE WAS IN THE LONGEST1 I O. OTHER I S. SUBSIDIZED CHILD CARE MI IS TIE STUDENT A SINGLE PARENT? I YES I NO 116) CURRENT GRADE LEVEL NO 05 TRANSFER INFORMATION: (171 NAME OF SCH001 TRANSTERFING FROM MO CITY CR LOCATION K91 DATE Of LAST ATTENDANCE (201 GRAD! lEvIl. Ill) LAST PUBLIC SCHOOL ATTENDED IN PALM BEACH IALPITI .121 DATE ATTENDEE FREE OR REDUCED PRICE LUNCH AND HEALTH INFORMATION: 1231 NAVE TOL FILLED OUT AN AFPLICATION FOR FREE OR REDUCED (APPLICATION IS PROVIDED WITH THIS REGISTRATION FORM) LUNCH? I es l NO (241 HEALTH SCREENINGS: I GIVE PERMISSION FOR MT CHILD TO DE GIVEN HEALTH THESE TESTS MAY BE GIVEN INDIvIDImitr OR IN GROUPS. SCREENINGS. NO 9 'ES I NJ US/ SODIUM FLUORIDE I GIVE PERMISSION FOR MY CHILD TO PARTI:IPATE IN 10 PREVENT DENTAL DECAY. PERMISSION IS VALID THF)UGE THE SODIUM FLUORIDE PROGRAM NO GRADE SIX. I . Ni NEW STUDENTS TO PALM BEACH COUNTY: HOME LANGUAGE SURVEY MO WHAT LANGUAGE IS SPOIEN IN THE HOW Br THE PANENT or GUARDIAN: (2?) MEAT LANGUAGE IS SPOKEN IN THE HOME 8Y THE STJOENT? '28) DATE 0, ENTRY INTO THE ESOL PROGRAM (211 LANGUAGE SURVEY I. IS A LANGUAGE OTHER THAN ENGLISH USED IN THE NOME? 2 DOES THE STUDENT HAVE A FIRST LANGUAGE OTHER THAN ENGLISH? 3 DOES THE STUDENT MOST FREQUENTLI SPEAK A .ANEUACE OTHER THAN ENGLISH? I TES ,YES I YES I I I NO NO No (30) DISCLOSURES !of HIM estry leo this SCHOU DISTRICT HAS THE STUDENT EVER: I. BEEN EXPELLED !ROM SC11031? 2. HAD AN ARREST RESULTING IN A CHARGE? 3. HAD ANY JUVENILE JUSTICE ACTIONS? I YES OYES Ira 9 NO I NO I NO EFTA01709705 THE SCHOOL DISTRICT OF PALM BEACH COUNTY - NEW/RETURNING STUDENTS REGISTRATION BACK I3IT STUDENT LIVES WITH (CHECK ONE) il 0011% PARENTS II MOTHER 0 FATHER SHARED CUSIOD) u OTHER (32) TRAP/SPORTED TM Suds,. wt. 64 isompe•toli tilfront awl Ey Mama A at., Man gra(THO (33) IE THERE A COURT ORDER DARRNG LITDER PARENT FROM REMOVING OR CONTACTING THE STUDENT MANG TEE SCHOOL DAY/ E YES ONO IF YES, PLEASE PROVIDE THE SCHOOL WITH A COPY OF THE COURT ORDER /34 FAT GUS DOES FATHER KAYE CUSTODY? OYES 0 NO YES (70) MOTENR/GLEARD/Ail DOES MOTHER HAVE CJSTODy: 0 YES ONO YES nor wawa Ham Leal ..3, A.M. NOM .Mir HERS maim cm Han Sta./ArAH PIA= OF SHRO•War pi..,“ 0, ,,,,,.. 0, XBPR mom Ham 'wan Hwy .....,.... Women nom QM NIGHLST LEVEL OF EDUCATION COMPLETLD (OPPONL1) A O "" ".." B O "..lir C O"4" ... a ItIRADUATEI 1371 Ads HIGHEST LEVEL Or EDUCATION COMPLETED (OPTIONAL) wwrmw..., B O I'm` -;,saca„ C Deltic"' D O „..... -- --- “7,- E O ""-"'" 44 ,, -JOMI D O ' ' "'„, - E O ''""',":" „ (SR LEGAL GUARDIAN IIF ANY) COES LEGAL GUARDUJI NAVE CUSTODY, O YES O NO TIENTMal msoriaMas twr---- Icor — 1,15:6I 0421PATHit Kan OS HAtar...MT 'SAM nal EMERGENCY HEALTH AND SAFETY INFORMATION PART I PERSONS, OTTER THAN PARENT AuTHDRIZEO TO PICK UP STLIDENT • (391 PASSROAD (OMIT '0 CHARACTERS) AS AN1041.1ZD 4(4440044 POOP I4II NAME ADDRESS PHONE RELATIONSIIP U I-I YES O NO WM MAC ADDRESS PHONE IMATIONIHIP U I-. YES O NO PHONE RELATIONSHIP U I-I • YES NO 1113) MME ADDRESS 1441 (MME ADDRESS PHONE RELATIONSHIP m O YES to GEM Walt ADDRESS PHONE RELATIONSHIP u/—) YES O 10 (46) PART II ' SCHOOL PERSONNEL ARE UNABLE TO CONTACT YOU IN CASE Of ILLNESS OR ACCIDENT, MAY WE HAVE YOUR PERMISSION TO CALL TOW DOCTOR OR EMERGENCY SERVICES 19111 FOR TRANSPORT -0 THE HOsPiTm.? Dm D ND (47) TANEY DOCTOR INFANTS a CHILD T;481 PHONE NULetR 1491 HOSPITAL PREFERENCE ISO) LIST YOUR CHILD'S ILLNESSES, ALLERGIES OR OTHEP PHYSICAL LIMITATIONS YOUR CHILDREN IN OTHER PALM BEACH COUNTY SCHOOLS: IS II NAME OP CHILD SCHOOL ATTENDING STUCENT NO (OPTIONAL? GRADE BIRTH DATE IS3/ NAME Of CHILD SON.H.I. AT I LAIJING sruoENT NO. (OPTIONAU SIAM MTN DATE (531 NAME OT MO 50400E ATTEADOPT STUCENT NO. (OPTIONAL/ GRADE IIIRTPI DATE (04? NAME Of CHID SOIOCL ATTENDING STUCENT NO. (OPTIMAL/ MADE BIRTH DATE (ES) NAM( Of CHILD SCHOOL ATTEMANG STUCENT NO. (OPTIONAL) MAIN BIRTH OATS OM I VERIFY THAT THE INFORMATION GIVEN IS TRUE AN) ACCURATE TV THE BEST 0I MT INOWLEDGE. 8 /9 qd DATE FOR OFFICE USE ONLY: cc>, UNITS NO Mu truhlort NutFAIR (St 51110 HT LAWIIAM EN DM CEO US NM NUT CODE EO1 MD INES( Oslo O8/18/88 (531 SAC LOBE OEHIC (65( GRADE LEN( 05 LSO CALENDAR 01 S1 EAT/INNO 507 (54, PARENT/GUANO:AN LANGUAGE EN OB1 REASSIGNMENT CODE EIA.ADM 0 E•fst .65) 7RANSPDATATION ChEs 0 NO -70) LIRIEICATICN OE 8 NTH ITU MIS ;721 DOCUMENTATION OliECILOST CCM°. ANT DATE MEN FIECEIYEDI o cATT HMALNIZATIONS 0 CATE sVIEwto RIPICittAToolORNDO: 0estsot OlisMAG 0 1 2 3 4 6 6 1 1 3 4 6 B 7 0 9 T A Z 8 1 Dm SOCHA SEGE-Air( n ,,,, 0 ,,,,ONA, L.' CIATf PHYSICAL LxAmS (73) OAT/. MR, (CAPUT(' St: DATE PESO 0636 LREV. 3)18) EFTA01709706