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Mehlville PAT Enrollment Record
This section to be completed by mother/guardian of the child(ren).
1. Last name
2. First Name
3. Marital Status
Not married but living together
American Indian or Alaskan native
Black or African American
Native Hawaiian or Other Pacific Islander
7. Language used most often
8. Last grade completed in school
9. Currently Employed
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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