ns taken against him/her. 0 The student has arrested resulting in a charge. (30) STUDENT LIVES WITH: (check one) 0 Mother 0 Father 0 Both Parents 0 Foster 0 Group Home (31) CUSTODY STATUS OF STUDENT (aeck tee) 0 Mother 0 Father 0 Shared Custody E Other • Other CRS: SEC:OO1 BLDG:O3 RM:212 O6 11 O4 IMPORTANT

actions taken against him/her. DI The student has wrested resulting in a charge. (30) STUDENT LIVES WITH: (chock ro D Mother 0 Father oth Parents 0 Foster 0 Group Home 0 Other ' (31) CUSTODY STATUS OF S7111:Off (check one) 0 Mother K Father 0 Shared Custody 0 Other IMPORTANT INFORMATION - MUST BE COMPLETED t

hool. • The student has III The student has arrested resulting In a charge. (30) STUDENT LIVES WITH (check one) 0 Mother 0 Father 0 Both Parents 0 Foster 0 Group Home 0 Other (31) CUSTODY STATUS OF STUDENT (check one) 0 Mother 0 Father 0 Shared Custody 0 Other NBR:O23 STDT: CRS:21O46OO SEC:OO4 BLDG:O2 RM:2