Mehlville PAT Enrollment Record
Mother/Guardian Information
This section to be completed by mother/guardian of the child(ren).
1. Last name
Your answer
2. First Name
Your answer
3. Marital Status
Choose
Divorced
Married
Not married but living together
Separated
Single
Widowed
4. Age
Your answer
5. Ethnicity
Hispanic/Latino
Non-Hispanic/Latino
Clear selection
6. Race
Choose
American Indian or Alaskan native
Asian
Black or African American
Multi Race/other
Native Hawaiian or Other Pacific Islander
White
7. Language used most often
Your answer
8. Last grade completed in school
Your answer
9. Currently Employed
Part-time
Full-time
Not employed
Clear selection
10. Occupation
Your answer
11. Active Military
Yes
No
Clear selection
12. Do you have Health Insurance?
Yes
No
Clear selection
13. Are you eligible for Medicaid?
Yes
No
Clear selection
14. Are you eligible for Food Stamps?
Yes
No
Clear selection
15. Are you eligible for WIC (Women, Infant, Child)?
Yes
No
Clear selection
16. Are you eligible for Public Housing?
Yes
No
Clear selection
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