Pancho - CAM-IRL-79

Code: CAM-IRL-79
Mercy ID: V-01980-01
Encounter Date: 08/11/2005
Last: Campos vazquez
First: Irlanda suzuki
DOB: 11/06/1979
County: Dekalb
Street: homeless
City: Homeless
State: GA

Zip

00000-0000

Home

(000) 000-0000

Family Status

Single parent w/children

COB

Mexico

Gender

Female

Housing

Street

Education Level

some high school

Home Owner

No

Parents Information

	Name	DOB	COB
Mother	N/A	N/A	N/A
Father	N/A	N/A	N/A
Step Parent	N/A	N/A	N/A

Driver: No
Relative: No
Stranger: No
Lives With: N/A
Name of School: N/A
Grade: N/A
Who Can't Pickup the Child
Authoritation Parent: No
Authoritation Child: No
DOY PERMISO: No
Limitado Educativo: No
Limitado Impresos: No
Limitado Caminar Latino: No

Intake: J. Perez
Data Entry: K. Aleman