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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
6. Race
7. Language used most often
8. Last grade completed in school
9. Currently Employed
10. Occupation
11. Active Military
12. Do you have Health Insurance?
13. Are you eligible for Medicaid?
14. Are you eligible for Food Stamps?
15. Are you eligible for WIC (Women, Infant, Child)?
16. Are you eligible for Public Housing?
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