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)

he 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 the student ever had any Juvenile Justice actions? (31) CUSTODY STATUS OF STUDENT (check one) • Mother 0 Father El Shared Custody 0 Other MN Is there a court order barring either paren

0 Yes (Permission is void through grade 5.) 0 No 6. Does your child currently have health Insurance? ;Yes Q No p If YES, check insurance plan: 0 Medicaid 0 Healthy Kids/Kid Care IXPrivate K Interested in receiving information 7. All new students to Palm Beach County are required to answer the followin

40 STUDENT LEGAL NAME MN Rat middle) 9. Disclosures for entry into Palm Beach County School District (check all that apply) O The student has had Juvenile Justice actions taken against him/her. 0 The student has been expelled from School O The student has been arrested resulting in a charge. Ef Not applicable

0 Yes (Permission is void through grade 5.) 0 No 6. Does your child currently have health Insurance? ;Yes Q No p If YES, check insurance plan: 0 Medicaid 0 Healthy Kids/Kid Care IXPrivate K Interested in receiving information 7. All new students to Palm Beach County are required to answer the followin

93 STUDENT LEGAL NAME MN Rat middle) 9. Disclosures for entry into Palm Beach County School District (check all that apply) O The student has had Juvenile Justice actions taken against him/her. 0 The student has been expelled from school O The student has been arrested resulting in a charge. ErNot applicable