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PAT Enrollment Form
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PAT Enrollment Form
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Indicates required field
Parent Name
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First
Last
Parent Name
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First
Last
Date of Birth
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Date of Birth
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Race
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American Indian or Alaska Native
Asian
Black/African American
Hispanic/Latino
Native Hawaiian or Other Pacific Islander
White
Other
Race
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American Indian or Alaska Native
Asian
Black/African American
Hispanic/Latino
Native Hawaiian or Other Pacific Islander
White
Other
Education
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Some High School
Completed High School
Some College
Associate's Degree
Bachelor's Degree
Master's Degree
PhD
Education
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Some High School
Completed High School
Some College
Associate's Degree
Bachelor's Degree
Master's Degree
PhD
Language most often used
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Language most often used
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Marital Status
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Single
Married
Seperated
Divorced
Widowed
Marital Status
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Single
Married
Seperated
Divorced
Widowed
Employment Status
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Unemployed
Part-time
Full-time
Employment Status
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Full Time
Part Time
Unemployed
Phone Number
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Phone Number
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Address
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Line 1
Line 2
City
State
Zip Code
Country
Email
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Email
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Child's Name
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First
Last
Date of Birth
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Child's Name
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First
Last
Date of Birth
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Premature at Birth
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Yes
No
Gender
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Male
Female
Birth Weight
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Please list any medical conditions (current and previous)
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Are your child's immunizations current as of today's date?
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Yes
No
Premature at Birth
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Yes
No
Gender
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Male
Female
Birth Weight
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Please list any medical conditions (current and previous)
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Are your child's immunizations current as of today's date?
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Yes
No
What is the best time for a personal visit?
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Daytime (8AM-3PM)
Evening (3PM-8PM)
Anytime
How did you hear about us?
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School
Doctor
Friend/Family
Other
Does your family qualify for any state assistance?
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Yes
No
Additional Information
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