EFTA01246758.pdf

.... - ....... .. . -.... .......... ........., TO THE PARENTS OR GUARDIANS: f ) . NEW/RETURNING STUDENTS tlej.g NEW STUDENTS: Complete all non-shaded areas. RETURNING STUDENTS: Please review both sides for ucrotuart RESI STRATION 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 e.. < information and writing the correct Information above it. TOO NT 'S LEGAL II (2) ALSO 010 it AS ... %.e t I 0101e-MONNIC On OF ESTI (IS MALI VE MTN HO RESIDENT STATUS 12) GRAN UThl. 0 O. FOREIGN EXCHANGE STUDENT 0 I.I. OUT•OF-COUNTY RESIDENT Re ' Lies • 0 2. OUT•OF•STATE AESIDENT .' riel ) • O1 : i /qii ea melgArefa l 1 #412/ 024 Er; IN•COUNTY RESIDENT reenta IMPACT Am SURVEY W APPLICABLE' III) WS TICS CHILE SEEN ENTREE IN ANT PRESC1100L7 SI Is (be **Mel e Desk WINO (CHECK THE LET TER CODE FOR ONE CODE ONLY! . •'Please Flot• I thachisrt (14 by tub program elisHite. AIN. Islitale 3 I on on IN Nan. Mitiliry Soma. she. ao +OHIO I *1 ON prelim yoat pile N Ilit 'engem! ' 3 B ,..........,,,t. ..„,..z..... it .....t....: .at.zk...:: ,.. 0t. -CHAPTER I 00 PRE-C. OISABILITIES E. PRE-1 EARLY INTURENTION . 8 0 It MICRON PRE-11 N. NON-SIPOTIO1210 DOW CAW _,.. OTHER __ 0. I YES Eil fo std.., viss. N. WAOSTART at. SUBSIDIZEO CHILD CA F tagiSOVITANIVOrie&no if NAME Of SCROOt TR ERRING FACW Ill CDT OR LOCATION in OAT( OF LAST ATTENDANCE E7:7 a/4 4- - 016tel..eL—" ,t-i /995 tejLea4re it/t) 77. • CRAW (2W. f 120) UST MIRK SCICOL ATT(1010 PALM BEACH COUNTY L2 OISE AMINO 6 2 /1 1 )CL9 Zi e---• 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) SODIUM It 10E. I gin Ferelnite let Thy dill le be gist. beta Hite/Hags. Tem tens I give sem:idea ler my child Is panklpele in Il e swan Thestitle Preys* In mity be glees Intivilaally et In genes le pent* bait! decay. IttenIssiee Is *Ill none toils Flt. NS OK Dm Bcr Il romexcloativp.; QmelatiewAvgtscatateratagefogswaya, MS ' hil tna Nervy is spoken it The CM Mai 'engem Is spoken is RN OM el fury IMe CM bent, by 1St poem or Dwelt* St Hat by De Molt.' (SIX Pintas I. Ii • wens,. Hese INA &IN. 'a" '. n. ' eh.? ICS al* 0 CA_ cts-/- / . es_#,:s-/- 2. coos me ousts' kr. I hen lasevae• Ginn inn. eniNiNil 3. Cions us swam ant tie/wenn, ion,. • 'aorta,* itinst No This's? ORS EISO O ns El-tto RR EFICE.11Sgtrang, t. .3.-.,1. nlir4::4!X- apit io. i:r., f.aultMrliwt!erk- . • ': im, •.,:ile)irf;ls. PT Acr.. tl lOe (31 1 Cnr,1 00 CITE ITS/..The. I .I I I I i ' lici • tiiii i.i i .1. rini2it 2: c... 1 .1 . ; . -.—...._ .. L . Auss..y.ot:wiTicDc( C4 II PAIrk)...rf,r).A (9! .41, 1F1CA71,Th -.Q! ' hIE.11, .0. [ Iio :;;;;;•••:ni.'.! ..,..; (: ;Syr., ;O. ; , ...i.. 0,,q 'J.) N n)! ;iii , ji. S E , i' Lk', „,.,.., p, ., . ,,,---,...,- ,-, ' s LK 4. 4Ll.. 5' . ...-,.... .,..... 14YY311 _:, kait eir _. . ___ „It w .._ 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 FRONT MM08-M LICATA-000040 3501.135-014 CONFIDENTIAL Page I of 2 EFTA_00066381 EFTA01246758  U ." :riam a, I..1 vJ Gf I U U its*•• Her LAI LEGAL GUARDIAN If ANTI Oats Liam GUAAOIM HAW CUSTOM? UITS O NO to. tmo.d. 041 soattt TM Aosta Stan CCO/PAtIONI 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 ,J M. moss. In "ME a Pmdzo MD ADDRESS 11002126.41 / /"/ \ Y 14vAe 09-409617 WA ( l*e74, IS IP IS 8-ws Oi A411141-74 .17 qe-46 -1-46 0---Auf leelig , Amp,-Ilk953- 1" 44 0 No 0 YES 0 NO 0 lies 0 NO YES 0 0) ° _ FIS PART t N o..1 is HAW I• Awn% yr/ I I Ma •••14•4 say Ay ken yew ponesSo• ea vow Lwow •r •norrary Tonne PIO TES O N w••••••II HI NA ?..PIIA F DOCTOR ' 16.Et PHONE MAINER HOSP lamHOSPITAL PREPIINVI 0.7- 9300 eatt e/ ▪ µ.wra Oho. it w• Stead b• aware 4 Non Alt .7) NAMEMI OF CH:LOASO NODE C‘0>brat'Aii Oa ATTENOMG 1651 fNDExi D. I • MAL/ GflAD PO BIRTH DATE MM08-M LICATA-000041 3501.135-014 CONFIDENTIAL Page 2 of 2 EFTA_00066382 EFTA01246759