n form and apckaton must be received within 45 days of the last identifiable threat DATE0 MTN ULD YOU MEAL. CCRRESPCNDENCE NT BY EMAIL? ISSYES El NO STATE ft— cote 35401 INS INFORMATION IS COLLECTED FOR FEDERAL REPORTING PURPOSES AND IS OPTIONAL FLAMETHINICrY: rIAMERICAN WM ❑ASIAN I—I 8LACKA I

1154•CALCOu404 RA❑ aLlcaktal IIAACUAR 04 wow OYES • .4. "" M4APA4IP )g) LEGAL GUARDIAN (IC APO) R est eAs DOES LEGAL GUARDIAN HAVE CuSTOEY) El NO w,(ai LAST PC.it ACcilsi CITY ITA/1 2d COpI A .,. ,A ...,,,..... a Atm,. Arndt EMERGENCY HEALTH AND SAFETY INFORMATION PAnT I FERSOND) CINE

r) C(FY STATE. ZIP CODE 2ocak Pa_k m P)dr‘ FJ45.3(11 STATE 2IP COCC RELATIONSHIP cart 111O1 ) EC (40) AUTHORIZED FOR El ENCY PICKUP YES El NO TELEPHONE RELATIONSHIP (42) AUTHORlaiD FOR EIAIRODCYNacuP K YES O NO (43) If school personnel are unable to contact you incase of ithess or acc

daily by Medical Staff Has been seen daily by responsible Gera designated by Warden: Yes; K No Has recanted prescribed weeldy exercise: IZ Yea; El NO Proper documentation and justification in the Central Fie (Incident Report. DHO Report copes or Special Housing Review Form): Yea El No If no. why

e number (561) 355-438 within two (2) working days of your ceipt of this notice: if yon are hearing or voice impaired, call 1-800-9554771. SERVED El NO SERVE TIME 14,-/-71-XeM DATE -2 COMMENT 07/26/17 Page 110 of 124 Public Records Request No.: 17-295 WITNESS, The Honorable Circuit Court, as a