Epstein Secrets

MILY PHYSICiAN (46) PHYSCIAN PHONE (48) Does your child currently have health Insurance? 0 YES 0 NO If YES. Indicate (47) HOSPITAL PREFERENCE p Medicaid 0 Private • Healthy Kids, l60 Care ID interested In receiving information PARENTS/GUARDIAN'S OTHER CHILDREN IN PALM BEACH COUNTY SCHOOLS (49)

e date of entry Into an ESOL program? 0 032) silken LNES WITH (check one) Mother 0 Father 0 Both Parents 0 Other (33) DISCLOSURES FOR ENTRY INTO PBC SCHOOL DISTRICT YES NO 0 0 I. Has the student ever been e,pelled from school? 0 0 2. Has the student ever had an arrest resulting in a charge? 0 0 3. Has th

LY PHYSICIAN (413) PHYSICIAN PHONE µe7 Does your child currenV have health insurance? BYES 0 NO If YES, indicate: (07) HOSPITAL PREFERENCE . 0 Medicaid airivate 0 Healthy Kids/Kid Cam 0 Interested in receiving information eittiS •i p ER, tpl.PeEtliii,„_, ,,,,,_ cfrk oil _ ,§q. ,pp 73, (49) NA

an ESOL program? (32) STTENT IJVES WITH: kited cone) V2 Mother O Father O Both Parents VOtper ‘ 214t sbPstiCEWKS (33) DISCLOSURES FOR ENTRY INTO PBC SCHOOL DISTRICT YES 14)," O 4 . _A. Has the student ever been expelled from school? O ril i 2. Has the student ever had an arrest resulting in a charge? O NY

Y PHYSICIAN (46) PHYSICIAN PHONE (48) Does your child currently have health insurance? MI YES 0 NO If YES, indicate: (47) HOSPITAL PREFERENCE 0 Medicaid 0 Private 0 Healthy Kids/kQd Care 0 Interested In receiving information ASWALOA491.4:04iiit lit filierAlaffiblikr0S-1-101)1; . .. (49) NAME CF

he date of entry Into an ESOL program? (32) STUDENT LIVES %1111. &Saone) O Mother O Father O Both Parents O Other (33) DISCLOSURES FOR ENTRY INTO PBC SCHOOL DISTRICT YES NO O • 1. Has the student ever been expelled from school? O O 2. Has the student ever had an arrest resulting in a charge? O O 3. Has the