Pancho - TEL-DER-07

Code: TEL-DER-07
Mercy ID: V-03126-21
Encounter Date: 07/29/2009
Last: Tellez
First: Derek
DOB: 02/14/2007
County: Gwinnett
Street: 6308 Dunleaf Arc Way
City: Norcross
State: GA

Zip

30093-

Home

(678) 508-7063

Cell

(678) 754-0567

Family Status

Child/Youth

COB

USA

Gender

Male Child

Housing

Single Family

Education Level

Child, not in school

Home Owner

YES

Parents Information

	Name	DOB	COB
Mother	Elvia B. Rodriguez	02/25/1983	Mexico
Father	Ivan Tellez	01/16/1983	Mexico
Step Parent	N/A	N/A	N/A

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

Intake: C. Martinez
Data Entry: J. Manzo