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S I NO NEW STUDENTS TO HOME LANGUAGE SURVEY (26) WHAT LANGUAGE IS SPOSEN IN THE HOME 51 THE PAFANT or GUARDIAN. En ‘isk (27) WHAT LANGUAGE IS WILDE IN THE NOME BY THE STUDENT? . Eng\ ‘ 31-N 1281 DATE OF ENTRY INTO THE Mt PROGRAM 129) LANGUAGE SLAW I. IS A LANGUAGE OTHER THAN ENGLISH USED I
IST YOLR DOW'S ILLNESSES. A.LERGiEs OR OTHER PHYSICAL LMITATIONS YOUR CHILDREN IN OTHER CHOOLS: :Ill NAME OF CHILD SCHOOL ATTENDING STUDENT NO. (OPTIONAL) GRADE OATH DATE tl 4IN — STUDENT NO. (OPTIONAL) GRADE 1531 NAME OF CHILD SCNOOI ATTENOING STUDENT NO. (OPTIONAL) GRADE BRIM DAVE 1641 NA
tende bang index« enen. nemmes, and pas's. to Wild rrtcnnation for a vanety of aromen sYntheerand a
(4, GUn IVG ADDRESS .C./.1 he mar MAW( a, , ',We 41;ar orES Vrilt, 4• Ml s., 4. cn, sr *Tr t, car rrAW isi metiers SOCIAL SECURITY NO. (OPTIONAL) 161 HOME >HONE N0. il) I remAte 3 SEX F MALE (8) . e I RACE AMERICAN INNAN OP ALASKAN NATIvE. B ' NON-HISPANIC D A ttl iCti:IC I
S IN THE IONCEST / 0 0. OTHER 0 S. SUBSIDIZED WILD LAM (ESN IS THE STUDENT A SINGLE PARENT? 0 TES
GRACE BIRTH DATE 154) NAME OF GILD SCHOOL ATTENDING STUCENT NO (OPTIONAL) GRACE BIRTH DATE (55) NAME OF CHID SCHOOL AT HEADING STUCENT NO. (OPTIONAL) GRACE SIREN DATE ISO) I VERIFY THAT THE INFORMATION GIVEN IS TRUE AND ACCURATE TO THE BEST CF MT KNOWLEDGE. SIGNATURE OF PARENT OR AGE( GjAROIA
Entities connected to both Courtney Wild and OPTIONAL

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