Informations sur les enfants à charge

Instructions pour le client : Veuillez remplir les informations pour chaque personne à charge de votre ménage âgée de moins de 18 ans. Pour assurer un traitement correct, toutes les informations fournies sont nécessaires. Un formulaire par personne à charge.





    *Gender:(CHOOSE ONE)




    *Is the dependent enrolled in school? (CHOOSE ONE)




    *Reason why dependent is not enrolled: (CHOOSE ALL THAT APPLY)

    • Lack of physical exam or missing medical record

    • Lack of immunization(s) or record(s)

    • Lack of proof of legal guardianship

    • Lack of transportation

    • Other






    *If the dependent is enrolled in school, please select the type of school: (CHOOSE ONE)





    **Student Body: (CHOOSE ONE)

    • Nursery/Pre-School

    • Kindergarten

    • Elementary School

    • Middle School

    • Approved Junior High School

    • Adult Education









    *School County: (CHOOSE ONE)



















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