Pancho - GUT-JAC-03

Code: GUT-JAC-03
Mercy ID: V-03136-12
Encounter Date: 08/25/2010
Last: Gutierrez
First: Jacqueline
DOB: 11/18/2003
County: Cobb
Street: 388 Phillips Dr
City: Marietta
State: GA

Zip

30070-

Cell

(678) 663-7453

Family Status

Child/Youth

COB

USA

Gender

Female Child

Housing

Single Family

Education Level

Grade school

Home Owner

YES

Parents Information

	Name	DOB	COB
Mother	Evangelina Rodriguez	02/07/1974	Mexico
Father	Francisco Gutierrez	N/A	Mexico
Step Parent	N/A	N/A	N/A

Driver: No
Relative: No
Stranger: No
Lives With: Mother
Name of School: Park Street Elem
Grade: 1st.
Who Can't Pickup the Child
Authoritation Parent: YES
Authoritation Child: No
DOY PERMISO: YES
Limitado Educativo: No
Limitado Impresos: No
Limitado Caminar Latino: No

Intake: C. Martinez
Data Entry: J. Manzo