Epstein Secrets

ne only) te Both Parents 0 Mother 0 Father 0 Foster 0 Group Home 0 Student is ward of the state Ot

been arrested resulting in a charge. of applicable 10. AInd with whom the student lives (check one only) te Both Parents 0 Mother 0 Father 0 Foster 0 Group Home 0 Student is ward of the state Other 11. IMPORTANT, EVERYONE MUST ANSWER THIS QUESTION. A. Is there a visitation order or other court

(ophone0 (9) HOME TELEPHONE NO. (12) DATE Of MTH (13) MACE OF BIRTH (city, LS ceneery) (11MAXWYYY) (1C) SE:1 F (11) RACE/Ell-RICORIGIN Native 0 B-Black, Non-Hispanic 0 W-White, Non-Hispanic • I-American Indian/Alaskan • H-Hispanic 0 A-Asian/Pacific Islander 0 M-Multiraclal (14) 0 RESIDENT STA

(check one) 0 Mother 0 Father 0 Both Parents 0 Foster 0 Group Home (31) CUSTODY STATUS OF STUDENT (aec

name) (apt. no) (ulY) (stale) MP 0,(0!) BO SOCIAL SECURITY NO. Toptrone0 (9) HOME TELEPHONE NO. (10) F 1 (11)RACFJETHMC ORIGIN y • Native 0 B-Black, Non-Hispanic 0 H-Hispanic 0 W-White, Non-Hispanic 0 M-Multiracial I-American Indian/Alaskan • A-Asian/Pacific Islander (12) DATE OF MTH (leAUDD

WITH: (chock ro D Mother 0 Father oth Parents 0 Foster 0 Group Home 0 Other ' (31) CUSTODY STATUS OF

RITY NO.PAPLOneg (I) HOME TELEPHONE NO. (10) S 1 F (I1) RACErETNNIC ORIGIN 0 I-American Indian/Alaskan 0 A-Asian/Pacific Islander W . Native 0 B-Black, Non-Hispanic 0 H-Hispanic 0 NI-Multiracial • W-VVhite, Non-HiSpanic (12) DATE OF BIRTH M TMARDCWYY (13t PLACE OF BIRTH (c4 stab. couphy) WEST