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
Choose
Divorced
Married
Not married but living together
Separated
Single
Widowed
4. Age
5. Ethnicity
Hispanic/Latino
Non-Hispanic/Latino
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
8. Last grade completed in school
9. Currently Employed
Part-time
Full-time
Not employed
10. Occupation
11. Active Military
Yes
No
12. Do you have Health Insurance?
Yes
No
13. Are you eligible for Medicaid?
Yes
No
14. Are you eligible for Food Stamps?
Yes
No
15. Are you eligible for WIC (Women, Infant, Child)?
Yes
No
16. Are you eligible for Public Housing?
Yes
No
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