EFTA01709700

Sit • SEX RACIAL/ETHNIC GROUP 0 Hispanic t i.cAlhae, Not Hispanic 0 American Indian/Native Alaskan Legal 0 Black, Not Hispanic 0 Asian/Pacific Islander 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: P G OA BIRTHPLA• CURRE Name Street 2, qfjyst Entes his District Withdrawal Date Withdrawal Date Withdrawal Date City yes,/ School . Grede. G,..51. Glii i Gradig $ Cre4 K School Year. 19. 23-- -19 -9.g.-- School year. 19 gq .19 (15 School Year 19 -19 School Year: 19 -19 /7 School Year. 19 Cl r l •19 A__ Days Present: Days Abyt Days Present Days Absent: Days /Present' Days Absent: Dan Prieg:9 Days Abs. Days Prose : Days Absent / & Bit i if 1641 1 /625' /40 16 lf Subject Teacher Mark Subject Teacher Mark Subject Teacher Mark Subject Te er lk Subject Tea her rk MATHEMATICS MATHEMATICS i MATHEMATICS MATHEMATICS MATHEMATICS READING READING READING READING READING LANGUAGE LANGUAGE LANGUAGE _LANGUAGE LANGUAGE SPELLING S"ELLING SPILLING SPELLING SPELLING HANDWRITING g HANDWRITING iS HANDWRITING + HANDWRITING HANDWRITING SOCIAL STUDIES t2 SOCIAL STUDIES V _SOCIAL STUDIES SOCIAL STUDIES _SOCIALSTUDIES SCIENCE end SCIENCE end V SCIENCE end HEALTH vel l— SCIENCE and A , SCIENCE end HEALTH HEALTH BEHAVIOR COOS AVERAGE 3 HEALTH BEHAVIOR CODE AVERAGE 3 BEHAVIOR CODE AVFRAGE °it KAI TH BEHAVIOR CODE AVERAGE 5 BEHAVIOR CODE AVERAGE 3-- Indicate. Irdicate. Indicate: Indicate: Indicate p O cc Promote (PI Patent (Et) Summer School 15$) p Promote IP) Retain (RI Summer Schaol1551 Promote (PI Retain IR) 11pierner School (551 P Retain (RI Summer School (SS/ Promote (P1 Retain IR) Summer Scnocd (551 f ) 4:E Gracie: School. Guide. School. Grade. School Grade. School. Grade: (...) 5 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 D Present: 0in Absent: Days Poison! Days Absent: Days Present Days Absent: Days Present. Days Absent: Days Present: Days Absent: u.i CC CC C an i 67n 02 4 / o Mark I— z Subject Teacher irk Subject Teacher 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 SPELL IND SPELLING SPEI LING SPEI 1.1110 i HAND1M3ITING HANDWRITING HANDWRITING HANDWRITING HANDWRITING CC cE to SOOAI STUDIES SOCIAL STUDIES SOCIAL STUDIES SOCIAL STUDIES SOCIAL STUDIES Lu , Q. )- •,_, SCIENCE and SCIENCE and SCIENCE and SCIENCE and SCIENCE and ...Er a REALTY HEALTH HEALTH HEALTH HEALTH -.a 0 fg, BEHAVIOR CODE BEHAVIOR CODE BEHAVIOR CODE BEHAVIOR CODE BEHAVIOR CODE I —I L7 la,,. AVERAGE 1/4-.3 AVERAGE AVERAGE AVERAGE AVERAGE K • la Irvikate ..p Indicate: Indicate: Indicate: Indicate: .e, '—^•• net Promote (P) Promote (P) Promote (PI Promote (P) - .-. Retain IR) _ _ Retain IR) --. Retain Ifll ciiismai School (SSI Summer &tool (SS) EFTA01709700 SECTION 2 SECTION 3 CONSECUTIVE SCHOOLS ATTENDED CHECKLIST OF CUMULATIVE DATA Date Date Signatat Sending School/Address Contents of the Cumulative Folder should be arranged in the folio% Enrolled Withdrawn Senn3l* order. Og% Date' 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 9/43 back of Special Characteristics Card 5.Registration Forms - most recent on top 4/0 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 TRANSCRIPTS SENT 12.Teacher/Counselor comments (behavioral Sivelure Sending servation, anecodotal records) School/Address Dale Sent 13.ESOL Student Reporting Form and ESOL School' Student Record 5/ 47.c. 14.Student Progression/Summer School Info! 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 • The individual responsible for the introduction of each item will place in' • The principal or designee of the sending school will sign to indicate the and date by that Item In ink. records are in compliance with stated requirements at the time they are sent. P8513 1018 (New 6/85) EFTA01709701 Year: 2003 Grade: 10 School Coder Optional Code: School Copy Pis Your Scores Verbal 52 Math 52 Writing Skills 40 INMSQT Scores wthio these rarges can be mitered b you 80 20 tso Zo eo National Merit Ranges -- Men® ion lelen memum nelertne =N. en Scholarship Corporation 44 U 48 56 16 44 (NMSCI Programs Selection Index Ma sand wen min 75% a when.. Ye., voted hose( two- 70% or onalemo0es 144 Percentiles Nab Dame Percentile 48 last Sff ttatyMit i oilman ve to 200 SAT Nadal 800 200 SAT I Math US 200 SAT II: Writing Test BU) The Schram Wei s the sun of min Sone lin we now mai stn inn one sennend nen men ma hied witid, Hoak ad MU} Jai 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 scorn NESE an h SArcem Man as at Mal same or em • t9 gas wants Me ago its scheesho armee (see revise). a •TM a Manta n teat le year Review Steward itt NIL a Aro_ Select.oe index means you do sd neat entry requirements Your a GO__ let %I.IS.7.'s %OS provarns See your re Henan t000taf Minn below isa 1.0e/Mar infer. Answers Rat EDia trAnn._ Amy_ „M r Males en leg 'Wert. 1.6. Ask for your 0 itig; e—I test book , AM back so you / 0 AAA I can see the Ill AcmGeo Entre Requirements questions. 11 Ili mArtn E Beni 4 Soma* you prA041 in I Rothe 2 I A m Ma owns Aux la Carman'. ANA I ItiLd Ada% 11 0 A m rua YE o enew to i h NE E W 2110•01004 1•00012 ▪ tiro Tr A of ri Arm E ASS ensally. o Wed 88 CA Pi Na o MO I/ WM& • SehAlg E K lima te ant si oldest 12: O EAR “ A I Pi OM mpruvinc 4 m Nam Quantlaate fi at • Ann Al e_ o / • o•• Sentences 0.S. ISIS n inn Caperierrie _72_1_ A m ino Oen 24 I A m Al; C YES Nth Mast& __E4 D A es NIA hem • 25 if S Arm rn 205_ _A D 1B 13 0_ B les.. 0 ge c b ahes' end &Moroi collets xi 2C•6 or nor V a 27 • • m Anti 27 c o rn take ma PSATM•050T ',sin in Sy C AS/ A 044 IF re h Geo m No -117ar 28 0 29_A_ O. B m milINN IOW ovnice .earl) year) 01 wean *Dina*, $2 le ...nor warm% A 0 ti si C e ii Alg E A tn A • - WGeo e. A ✓ m Your Educational Plans —ILI 0 h A n 33 E ta t., 34 5 Dade Average C Impronn; c p o e m College Major PrIena4011Y Paislants 38 l 37 :A B e: t A 38 D A in Win F B in Photorapis 39 Wanton tow 6 selimialed CleaCeigellawl: Itycholegy miler YC° nvitrad C000Gfl 12 Of 39 weing eons 1,44y IIVITIOM !MI Ammar abet mcatiou aid tamed 12 Vidal and swore ma patelital I . . 2 of s annexe:4K ,nvo/ved I. normal and abnormal Inotnygs. %tags. and Seigel of ya medisp mestons Students 'toy.** Batt ana t. Af 7 lard quesions acmes. d beNmot erste S teno a • learning psychelOg.cal fads. RN I Mir VD/ Quilled 0 oJesbat(s,. rnetheal. riot Pies end areal' Yoe araered arra* se Sc rail ■ anis ammo Mfr.% irat.got fl out In•Madeeli end peen sed AMIN RIM% Yw anmeied eActreaN a7 q.esten(s) end 'rouge EFTA01709702 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. Sincerely. 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 Math Writing Skills Scores 52 40 INMSQT National Merit AS 56 41 51 36 44 Scholarship Corporation INIASCi Programs Selection Index 'Ow aporef higwr pi, 76%.. »rowan Yea seem nee. mon 70% os meranowo You sated hytl.,Aiwa 12% et wiesseenes. Percentiles 144 " 5014 50% Percentile 48 MSS OW pithililibl What SAT WA selotteeel eswe Ranges Can ' L i SAY I Verbal 800 SAT I Math SAT II: Witty Test %SUES Wait the cod You Expect? NINO MMIIMINI I= == =WI Nonme S MI C Ind Sint dar -- 300 600 When Snag pa earn refer to the pastors n your test book AC qui seStt Mebane rare a sto beef co e eery mat Mate Ma es en serum of eat 13 at gents viho mho is 33301010 Mom (see rc000l• e5C3 :04/S ‘ rt,CXY -Ma .. in tI M1 to yore Review clertifyirg entence Errtrs I D E . Seradlern 'now you do not meet tan, morreentMs Your Answers ; D a Et iE ✓ m rri m to. NV$Cr. AOC ercgramo Sat vrad nODOntes to enter ns below and WIN, mne mean on the nesse Ada Ask for your 6▪ B E 7 5 E m test book 0 0 / is; back so you g A EW can sec the X A C in GOO ✓ WI / Entry RequInsmenta questions. r d n it 1 m orth A F l ntarronoo leo prated PoHoil is U tAmAle C ✓ m on yes away sheet IS C s7 M Am 13 t ✓ in Ful-bne bott toed Cant li _A _ IL_mnti__ IS D E eta 11 D C h Gee E KAI 11 C I h any ie . View aegis eon Atm aid • COM:l ft A I Is AM 17 8 E W amt Wane r cash. o WOW II D A h All zees B t ii *Cr c F Yeas to to gene 03des1-17: • fay p AS (I h AIII OPP Improving E A a rn It C V • Ant 0 .V &Geo Sentences US avow* t lied . mc nLa Aic rn Al _tt_x_ A m YES AI2 feitrn zi 23 II Ca Ara keno NOTE —ST,Tdare who will as 2$ al lite Am awing high whoa and mitring Get Goren Sentence 2$ A_Ic • n AI men N ed_ cozen m 3021 or late mutt 22 CAM Nth ten. the PSAHMISIST awn m Coos ar up, to tree is 0 1 mole 0 0 rn INS year I suer year: re" n o i m Art 29 Atm grapes a throvell 12 Wemo• NIASC poppet 3; Aflame 3Ati 3i CST Mg _q1_E Am ✓ Act h liho _it_ A_✓ m Your Educational Plans 73 E A m se e o • Brats Average C Pallgt3014 •a N B Collop kW Posen $ C t A en Ar_c_sc_oe 37. A IS Career . 30 . D Am D t h E B m Pheleirateshes 39 A Inalatbn tett a tilt. teed bake 41 • C m Ycu ductal cove:1012 of 30 WangSUS otescoption: Psycnolow rotors sn eddy hunt% awl SION, holtanor (22SIJOIS aid earned 12 rent[ and Waled the pregite• 2 of • easy quietens involand o normal 04 Maroon& Scoring oi• nco ._ 10 0(23 medium rpestimu Marta twtlrgt. end saws Students istnatil Heir LAMM' Edna se- o of 7_ 1.3td queelons punts d 1Wheteer while * Ste learnMo illWM1001Cal WS. PUJEl POW .Th eac sontad correct at do* man ree earned 0 quetton(p. menace. primates all 'Witte!, sEnt Millen About Adrvidualt all • ISM quagga and aerial 24 pitta YEu arunztd incerrecrhi? %molts) and groups KNOX sc ow. 14 al it easy qudans led 7 /WHO N am mars ewe 7 II 13 rrediun quesbom Associated SKIN. Ora ell rime communaatoe. Inge! ems ailment - 3 of TO had qt.:sacra mane C A in INN IA PONA You EMS 2 pretWI(t), ReCCenmentled High SCITOW ills Mel IMP You oramd aura at du total tee Steads • Yea roved incorreCtit 14 asiectionth anf Co..,.. En 'Cl. emarwe caution ad rad n Pato Iasi 3 pings). rat/omelet v3. twiny 3. Meaty VMS la POPP social Otalist 2. hoots 1Ld1i autritalito conpaga 3, and computer • Wee neon le WO 14 04 n rnedllotrain science I 11-44 Co LOOT TOWS _d_14 bled Thad! Other Illajors to Consider You witted o sueston(S. Antnraporegy. Gore...rely. Seto Ont. xi Iota! work Sot OM, brach "..• Lir •••, ;IC 11,1 Ms ironed. innate:0c 20 quisteits) and Estnecishoudeloos. Coons medicine. urbanstreet and womana studies Carters: The undevaouste ■ UnderslaidicEp main ideas in a III Recognizing patterns and equetelent nabor it ;mythology an lad Improve rending passage forms le Mt. as a dwnseer ernanairtrons retn Inn counsel yore, Your How to improve: Read the WWI) passage caretsny and try to deecrene trio author's How to IMptiern Iry recognizing a pattern by COMO!, MI5 a siewer best 'Ty mooting Or Rota. me howats. or emus or Sahel ' cans abusers It ran ad te Skills oral message. oractice insang distinctions between he maw Idea and suaporind detellS- rearranging trie given eawessiors in a Marra torn an. onalehrasesicsne sentence Work NOM IMO leacher more tames, with -• <L,., -'n the ca- wantons •1:1C e mentsl health w wool terra eerier with slats Or mush indices doling wit See questons 14, St, 22. See questions 24, 27. lie skit Jared .02stirWas0 written Engirt; h Welk with modal Pee/dation or • Comparing and contrasting Ideas See questions 5, 7,9. • emotion& dilaNtitiet it isono are based on '• mod preparation tor Naar study presented in two passages ire's l a w, timslorw. social • Understanding the structure of New to Improve: Pose sideoriaa that take 1.0 . law putrid lawn strelon. sentences that relate to the arts ooposeg news Or an !Slue. Look 'or d tteronses and alreileaties In Iona, poet • How lo krprorre: Focus on hove sconeCithp 0' Wen, and main idea. said es well as on what IS SSA. Read articles or the test and See OUCS1011% 41, 50, 52. in no...editors and rnageenos seen tic ens 30 that you wi l reel more com'orleble with epresint those that • Applying Ideas presented M a 0C30 aublOcla con hire the nest reading passage Seel elUe.3:10413 14,:0. dome to improve How to improve: When you read, try to deter - (Ono Ina &UMW with ern work. Werra era assumptions sea Men bank abbot how Mow might IIPC4Y A new srtuatons. the Fellow See questons 41. 42. SO suggcstors to mime in each area. EFTA01709704 ,1 600L 0 THE SCHOOL DISTRICT OF STUDENT NUMBER: -V 0 -.Nxi PALM BEACH COUNTY VERIFICATION FOR NEW/RETURNING STUDENTS: I L TO THE PARENTS OR GUARDIANS: ,9NEW/RETURNING STUDENTS NEW STUDENTS: Complete all ron-shaded areas on bcth sides of form REGISTRATION RETURNING STUDENTS: Please review both lidos for correctness of typed information. If the information printed is into rest, please correct it by carefully ISTR ICFIR: TNBR: and lightly crossing out the incorrect information and -. .•', 8/12/98 HARM: 507 writing the correct information above it. 10 STUDENT'S LEGAL NAME (21 ALSO KNOWN AS Illllllllf I_ / ILL LOCAL AD IA MAILING ADDRESS U)w No. SIAM RANI AlT .16 LOXAHATCHEE FL 33470 t'ATT ZIP ICCF T.TV ,,,,,, Z• COPE ILL STUDENT'S SECT A: siCuR,Tr NO. 16) HOME PHONE ND. 01 SEX Er AN RACE W (OPTIONAL/ ASIAN OR K TEAP-E I arA NLZ IAINsu rTivi I A I W I tHISPANIC NOV-HISPANIC I HALE 9 8 e`"‘ NON- H.SPANIC 9 H HISPANIC 9 M ItALTJ.ACIAL 151 DATE OE BIRTH 001 PLACE Of BIRTH • US Now,. Oar WA* Cry VIAPE Cale. III) RESIDENT STATUS 3 (12) ENTRY DATE INTO USA 0 FOREIGN EXCHANGE S- UDINT 2. OUT-OF-STATE RESIDENT 9 I I. OUT-DE -COUNTY RESIDENT 3. IN-COUNT, AESIDtNT 0 I 1131 IEDERAL IMPACT Mc SURVEY YES I NO A. THE STUDENT RESIDES (N FEDERAL PROPERTY. YES I NO B. THE STDOEN' RESIDES IN LOW RENT HOUSING. I YES 9 II0 C. THE PARENT IS EMPLOYED ON FEDERAL PROPERTY LOCATED IN PALM BEACH COUNT,. I IIS I NO D THE PARENT IS EMPLOYED CN I3* RENT NCUSING LOCATED IN PALM BEACH COUNTY. MT, I NO L. THE PARENT is IN THE UNIFORMED SCATIGES Of TH! UNITED STATES. II WS, IS THE PARENT UN ACTIVE DUTY? I YES 9 NO AIR FORCE I ARMY 9 COAST GUARD I MARINES 9 NATIONAL GUARD I NAVY O41 NAS THIS CHILD BUN ENROLLED IN ANT PRESCHOOL' (PLEASE PLACE A MERRIAM I mix 81 EACH PROGRAM ATTENDEE. ALSO. INDICATE N WITH AN ASTERiSX I */ TO( PROGRAM YOUR CHILD WAS IN THE LONGEST1 C. CHAPTER I I H. HEADSTART I O. OTHER U. PRE-K DISABILITIES I M MIGRANT PRE-K I S. SUBSIDIZED CHILD CARE I E PENH EARLY INTERVENTION I N NON-SURSIDIZEO CHILD CARE MI IS TIE STUDENT A SINGLE PARENT? 116) CURRENT GRADE LEVEL NO I YES I 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 LUNCH? I es l NO (APPLICATION IS PROVIDED WITH THIS REGISTRATION FORM) (241 HEALTH SCREENINGS: I GIVE PERMISSION FOR MT CHILD TO DE GIVEN HEALTH SCREENINGS. THESE TESTS MAY BE GIVEN INDIvIDImitr OR IN GROUPS. NO 9 'ES I NJ US/ SODIUM FLUORIDE I GIVE PERMISSION FOR MY CHILD TO PARTI:IPATE IN THE SODIUM FLUORIDE PROGRAM NO I . Ni 10 PREVENT DENTAL DECAY. PERMISSION IS VALID THF)UGE GRADE SIX. NEW STUDENTS TO PALM BEACH COUNTY: HOME LANGUAGE SURVEY MO WHAT LANGUAGE IS SPOIEN IN THE HOW (2?) MEAT LANGUAGE IS SPOKEN '28) DATE 0, ENTRY Br THE PANENT or GUARDIAN: IN THE HOME 8Y THE STJOENT? INTO THE ESOL PROGRAM (211 LANGUAGE SURVEY (30) DISCLOSURES !of HIM estry leo I. IS A LANGUAGE OTHER THAN ENGLISH USED IN THE NOME? I TES I NO this SCHOU DISTRICT 2 DOES THE STUDENT HAVE A FIRST LANGUAGE OTHER THAN ENGLISH? ,YES I NO HAS THE STUDENT EVER: 3 DOES THE STUDENT MOST FREQUENTLI SPEAK A .ANEUACE OTHER THAN ENGLISH? I YES I No I. BEEN EXPELLED !ROM SC11031? I YES 9 NO 2. HAD AN ARREST RESULTING IN A CHARGE? OYES I NO 3. HAD ANY JUVENILE JUSTICE ACTIONS? Ira 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) OTHER u (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 MOTENR/GLEARD/Ail MOTHER HAVE CJSTODy: 0 ONO /34 FAT GUS DOES FATHER KAYE CUSTODY? OYES 0 NO (70) DOES YES YES YES ..3, A.M. NOM .Mir nor wawa Ham Leal HERS maim cm Han Sta./ArAH pi. ,“ 0, ,,,,,.. 0, PIA= OF SHRO•War XBPR .....,.... Women nom mom Ham 'wan Hwy QM NIGHLST LEVEL OF EDUCATION COMPLETLD (OPPONL1) 1371 HIGHEST LEVEL Or EDUCATION COMPLETED (OPTIONAL) A O "" a ".." B O "..lir C O"4" ... ItIRADUATEI Ads wwrmw..., B O I'm` -;,saca„ C Deltic"' D O -- „..... --- “ 7,- E O ""- "'" 44 D O ' ' "'„, - E O ''""',":" „ ,, -JOMI (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 I-I YES RELATIONSIIP U O NO WM MAC ADDRESS PHONE IMATIONIHIP I-. YES U O NO 1113) MME ADDRESS PHONE RELATIONSHIP I-I YES U • NO 1441 (MME ADDRESS PHONE RELATIONSHIP m YES O 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 Dm D ND DOCTOR OR EMERGENCY SERVICES 19111 FOR TRANSPORT -0 THE HOsPiTm.? (47) TANEY DOCTOR T;481 PHONE NULetR 1491 HOSPITAL PREFERENCE INFANTS a CHILD 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. ATI 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 DM CEO NM NUT CODE MD INES( Oslo (531 SAC LOBE EN EO1 O8/18/88 OEHIC (54, PARENT/GUANO:AN LANGUAGE (65( GRADE LEN( LSO CALENDAR S1 EAT/INNO EN US 05 01 507 OB1 REASSIGNMENT CODE .65) 7RANSPDATATION -70) LIRIEICATICN OE 8 NTH ITU MIS ;721 DOCUMENTATION OliECILOST CCM°. ANT DATE MEN FIECEIYEDI HMALNIZATIONS 0 CATE lORNDO: RIPICittAToo VsIEwto EIA.ADM 0 E•fst ChEs 0 NO 1 Z o cATT 0estsot OlisMAG 0 1 2 3 4 6 6 1 3 4 6 B 7 0 9 T A 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