Mehlville PAT Enrollment Record
Mother/Guardian Information
This section to be completed by mother/guardian of the child(ren).
1. Last name
2. First Name
3. Marital Status
4. Age
5. Ethnicity
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6. Race
7. Language used most often
8. Last grade completed in school
9. Currently Employed
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10. Occupation
11. Active Military
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12. Do you have Health Insurance?
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13. Are you eligible for Medicaid?
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14. Are you eligible for Food Stamps?
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15. Are you eligible for WIC (Women, Infant, Child)?
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16. Are you eligible for Public Housing?
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This form was created inside of Mehlville School District.