SEX RACIAL/ETHNIC GROUP 0 Hispanic
SEX RACIAL/ETHNIC GROUP 0 Hispanic
ti.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 Clrl •19 A__ -9.g.--
Days Present:
/ & BitDays Abyt
i if Days Present
1641 Days Absent:
1 Days /Present'
/625' Days Absent:
/40 Dan Prieg:9Days 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 vell— _SOCIALSTUDIES
SCIENCE end
HEALTH SCIENCE and
KAI TH A , HEALTH HEALTH HEALTH
BEHAVIOR COOS
AVERAGE 3BEHAVIOR CODE
AVERAGE 3BEHAVIOR CODE
AVFRAGE °it BEHAVIOR CODE 5BEHAVIOR 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 Ili 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:
024/ 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 ...Era
-.a 0 fg,
Ila,,. 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
Steno 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
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AS/ A
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NIL
a Aro_
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itig;
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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
fiat • 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 „Mr
e—I
E
E W
E
o
E K
Ale_
_72_1_ A m
C __E4 D A es
22 05_ _AD 1B 0_13
27 c o rn
28 0 B
29_A_ m
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33 Etat.,
34 5
c op me
38
37 :At A l
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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
ttatyMiti 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•010041•00012
ASS ensally.
MO
lima te ant si oldest 12:
4
0.S. ISIS
YES
Bb
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 flout 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 'Li
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
Nam 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 •
Coosar up,
bake $ C
Ar_c_sc_oe
D t h
A
41 • C m
sn
oi• nco
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scow.
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You oramd aura at du total
caution ad rad n Pato
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14 04 n rnedllot rain
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You witted o sueston(S.
Ms ironed. innate:0c 20 quisteits) and D C h Gee 1 m orth rdn it
IL_mnti__ 11
11 C I h any UtAmAle
IS C s7 M Am
li_A _
ft A I Is AM
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ii
p AS (I hh OPPAIII
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al lite Am
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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
dtteronses 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 DE.
; Da Ei rrim
Et ✓ m
6 ▪ B E
7 5 E m
0 0 / is;
g A EW
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IS D E
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ie.
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se e o
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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 of7_ 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
onalehrasesi csne 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 law, 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
IL
,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
I98SEX Er
KTEAP-E
HALE AN
I RACE W
arANLZIAINsurTivi
e`"‘NON- H.SPANIC I A ASIAN OR
9 H HISPANIC ItHISPANIC 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/ EYES 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 UI-I YES
O NO
WM MAC ADDRESS PHONE IMATIONIHIP UI-. YES
O NO
PHONE RELATIONSHIP UI-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
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DATE
FOR OFFICE USE ONLY:
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