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