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  r   ò  9                   Æ      ‚                      Â      Â      ‚      ‚      ò              Æ      Æ      Â              Â      +     ¼      ¼      ¼      ‚  X   Æ      Â      Æ      Â      Ì              ¼                                                      ‚      Ì              ¼              ¼      Æ      Æ                                                              ¼      Â      :      �â�GwÉ              Ú  p   ¼              H  „  A  0   q      ¼      7!      J    7!      ¼                                                                              7!              Æ      ¼  Œ   ‚      ‚      ¼      ‚      ‚                                      ‚      ‚      ‚      ò      ò                                      d  X                                   ‚      ‚      ‚      q      ‚      ‚      ‚      ‚              Ú      Ú      Ú    Þ  $   Ú      Ú      Ú      Þ      Ú      Ú      Ú      Æ      Æ      Æ      Æ      Æ      Æ      ÿÿÿÿ                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         C H I L D   I N F O R M A T I O N   F O R M   F O R   R E S P I T E   P R O V I D E R  M I S S O U R I   D E P A R T M E N T   O F   S O C I A L   S E R V I C E S  C H I L D R E N  S   D I V I S I O N    I .     R E S P I T E   I N F O R M A T I O N :  C h i l d ' s   N a m e :        F O R M T E X T                   	 	 	 C h i l d ' s   D O B :        F O R M T E X T               	  C h i l d ' s   M e d i c a i d   N u m b e r / D C N :        F O R M T E X T            R e s p i t e   d a t e s :            F O R M T E X T               t o      F O R M T E X T             D r o p   o f f   t i m e :    F O R M T E X T             a m / p m   P i c k   u p   t i m e :      F O R M T E X T             a m / p m  E m e r g e n c y   N u m b e r s :           F o s t e r   P a r e n t      F O R M T E X T                                  S o c i a l   W o r k e r :      F O R M T E X T           	 	 	 C h i l d ' s   P h y s i c i a n      F O R M T E X T           _ _ _ _ _ _ _ _                       	    I I .   C H I L D  S   B A C K G R O U N D :   A .     C h e c k   a l l   t h a t   a p p l y   t o   t h e   c h i l d :  S t r e n g t h s 	 	 	 	 	         F O R M C H E C K B O X       H e l p f u l           F O R M C H E C K B O X       I n t e l l i g e n t           F O R M C H E C K B O X       H o n e s t         F O R M C H E C K B O X       E n j o y s   a r t       FORMCHECKBOX  Dependable FORMCHECKBOX  Articulate   FORMCHECKBOX  Good hygiene   FORMCHECKBOX  Enjoys sports   FORMCHECKBOX  Enjoys music FORMCHECKBOX  Interacts well w/others    FORMCHECKBOX  Respects authority FORMCHECKBOX  Well-Mannered   FORMCHECKBOX  Accepts change   FORMCHECKBOX  Generous /Shares FORMCHECKBOX  Good with younger children   FORMCHECKBOX  Leadership qualities FORMCHECKBOX  Accepts diversity in others FORMCHECKBOX  Compassionate  Needs Support FORMCHECKBOX  Honesty   FORMCHECKBOX  Bedwetting   FORMCHECKBOX  Being Safe   FORMCHECKBOX  Sharing   FORMCHECKBOX  Hygiene   FORMCHECKBOX  Toilet training FORMCHECKBOX  Anger Management   FORMCHECKBOX  Not acting out sexually   FORMCHECKBOX  Nightmares / Insomnia   FORMCHECKBOX  Supervision around pets FORMCHECKBOX  Keeping things orderly FORMCHECKBOX  Tolerating redirection   FORMCHECKBOX  Accepting responsibility for behavior   FORMCHECKBOX  Not taking others property FORMCHECKBOX  Understanding due to lower IQ  FORMCHECKBOX  Close supervision by caring adult FORMCHECKBOX   Supervision w/younger kids FORMCHECKBOX  Mental limitations and abilitiesB.  Check all that apply to the child: FORMCHECKBOX  Suicidal  			 FORMCHECKBOX  Physically Aggressive	 FORMCHECKBOX  Verbally Aggressive   FORMCHECKBOX  Sexually inappropriate	 FORMCHECKBOX  Destruction of Property 	 FORMCHECKBOX  Fire-Setting  FORMCHECKBOX  Crimes-Delinquency  	 FORMCHECKBOX  Sexually Active		 FORMCHECKBOX  Substance Abuse   FORMCHECKBOX  Depression 			 FORMCHECKBOX  Elopement 		 FORMCHECKBOX  Medication needed FORMCHECKBOX  Medical (explanation e.g.:  broken arm) FORMTEXT                                                                                                                                                                                                                                                          \  Ð  Ò  Ô  Ö  	  &	  (	  <	  >	  @	  J	  L	  V	  X	  Z	  v	  x	  Œ	  ðÞÐÃ´Þ¨œ‘€t`€M€‘E:‘€t       h¡QA h¥O OJ QJ  h#O} OJ QJ  %j    h!« >*OJ QJ UmH nH u&�jÎ!  h¡QA hÏt8 >*OJ QJ U h¡QA h¥O >*OJ QJ  j    h¡QA h¥O >*OJ QJ U h¡QA h`iÕ OJ QJ  h <Ú h`iÕ 5�OJ QJ h <Ú h <Ú 5�OJ QJ h <Ú h <Ú CJ OJ QJ aJ  h <Ú h <Ú OJ QJ aJ  h¡QA h <Ú 5�OJ QJ aJ "h <Ú h <Ú 5�>*CJ OJ QJ aJ  j    h`$ï h¡QA CJ U^J       \  ª  Ò  Ô  Ö  	  ¤	  
  ë            â            â            â            b            ]            ]            ]            ]                                            gd`iÕ    kdZ!  $$If   –l Ö            ”Ö0   /(€/                €å"                
t  àÖ0   ÿ     ÿ     ÿ     ÿ     ÿ     ÿ  ö(6ö  ö  Ö   ÿ   ÿÖ   ÿ   ÿÖ   ÿ   ÿÖ   ÿ   ÿ4Ö   4Ö 
l aöl yt¡QA 	  $If   gd <Ú   $„Þü„"$If   ^„Þü`„"a$gd¡QA  	   *W  rW  þþ                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              Œ	  Ž	  �	  š	  œ	  ¢	  ¤	  Ö	  Ø	  à	  â	  ö	  ø	  ú	  
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  ìÛÈÛ½²½§½Û›‡ÛÈÛ½|Û›hÛÈÛ½Û›TÛÈÛ²½    &�j”#  h¡QA hÏt8 >*OJ QJ U &�j #  h¡QA hÏt8 >*OJ QJ U h¡QA h,WD OJ QJ  &�j¶"  h¡QA hÏt8 >*OJ QJ U h¡QA h¥O >*OJ QJ h¡QA hÓ-• OJ QJ  h¡QA h¥O OJ QJ  h¡QA h`iÕ OJ QJ  %j    h!« >*OJ QJ UmH nH u j    h¡QA h¥O >*OJ QJ U &�jB"  h¡QA hÏt8 >*OJ QJ U  
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      
      "  H  R  n  p  „  †  ˆ  ’  ”  ¦  Ê  Ì  à  â  ä  î  ð  ïãÏï¼ï±¦±ïã’ï¼ïã±¦±ïã~ï¼ïr±ïã^ï¼ï                   &�jZ%  h¡QA hÏt8 >*OJ QJ U h¡QA h`iÕ >*OJ QJ &�jæ$  h¡QA hÏt8 >*OJ QJ U &�jr$  h¡QA hÏt8 >*OJ QJ U h¡QA h¥O OJ QJ  h¡QA h`iÕ OJ QJ  %j    h!« >*OJ QJ UmH nH u&�jþ#  h¡QA hÏt8 >*OJ QJ U h¡QA h¥O >*OJ QJ  j    h¡QA h¥O >*OJ QJ U!
  $  ¬  j  n  ž     î    J  Œ  Â       <  ö            ñ            ñ            ñ            ñ            ñ            ñ            è            ×            Î            Î            Î            Î            Î                                                                                                                                                                                      	  $If   gd`iÕ   „h„˜þ$If   ^„h`„˜þgd�>    „h^„hgd�>    gd`iÕ    Æ à gd`iÕ  ð  ö      0  2  4  >  @  P  h  j  l  œ  ž     ¨  ì  î       õêÙÍ¹Ù¦Ùê›�~ri]rRrD6    h�> h†Rp 5�CJ OJ QJ h�> h`iÕ 5�CJ OJ QJ h�> h`iÕ OJ QJ  h <Ú h�> 5�OJ QJ h`iÕ 5�OJ QJ h <Ú h`iÕ 5�OJ QJ  jD&  h <Ú h`iÕ 5�OJ QJ U h <Ú h`iÕ >*OJ QJ h <Ú h`iÕ OJ QJ  %j    h!« >*OJ QJ UmH nH u&�jÎ%  h¡QA hÏt8 >*OJ QJ U h¡QA h¥O >*OJ QJ  j    h¡QA h¥O >*OJ QJ U h¡QA h`iÕ OJ QJ  h¡QA h‘B9 OJ QJ       .  0  2  H  J  L  h  j  l  Š  Œ  Ž  ª  ¬  ®  À  Â  Ä  à  â  ä  þ         ñÞÏ¹ÞÏ«ÞÏ•ÞÏ«„wc„w«„wO„w«ÞÏ                   '�j¤,  h <Ú h†Rp CJ OJ QJ U'�j0,  h <Ú h†Rp CJ OJ QJ Uh <Ú h†Rp CJ OJ QJ  !j    h <Ú h†Rp CJ OJ QJ U+�j¼+  h <Ú h†Rp CJ OJ QJ UaJ h <Ú h†Rp 5�CJ OJ QJ +�jH+  h <Ú h†Rp CJ OJ QJ UaJ h <Ú h†Rp CJ OJ QJ aJ  %j    h <Ú h†Rp CJ OJ QJ UaJ h�> h`iÕ 5�CJ OJ QJ              ,  -  .  ;  <  =  >  L  M  N  ]  ^  _  m  n  o    €  �  �  éÖÇ¹¨›‡¨›¹{¨›g¨›¹¨›S¨›¹¨›                                     '�j6/  h <Ú h†Rp CJ OJ QJ U'�jÂ.  h <Ú h†Rp CJ OJ QJ Uh <Ú h†Rp 5�OJ QJ '�jŒ-  h <Ú h†Rp CJ OJ QJ Uh <Ú h†Rp CJ OJ QJ  !j    h <Ú h†Rp CJ OJ QJ Uh <Ú h†Rp 5�CJ OJ QJ h <Ú h†Rp CJ OJ QJ aJ  %j    h <Ú h†Rp CJ OJ QJ UaJ +�j-  h <Ú h†Rp CJ OJ QJ UaJ  <  =  ^  €  Ÿ  5            ,            ,            ,                            	  $If   gd`iÕ  É  kd .  $$If   –l Ö            Öˆ hT¨°!È( ì                 T                                  T                                  ¼                
t  àÖ0   ÿ     ÿ     ÿ     ÿ     ÿ     ÿ  ö`'6ö  ö  Ö   ÿ   ÿ   ÿ   ÿ   ÿ   ÿÖ   ÿ   ÿ   ÿ   ÿ   ÿ   ÿÖ   ÿ   ÿ   ÿ   ÿ   ÿ   ÿÖ   ÿ   ÿ   ÿ   ÿ   ÿ   ÿ4Ö   4Ö 
l aöÔyt¡QA  �  �  ‘  ž  Ÿ     ®  ¯  °  Ë  Ì  Í  Û  Ü  Ý  ð  ñ  ò             ëÚÍ¿¬�‡¬�¿viUvi¿viAviÍ                '�j1  h <Ú h,WD CJ OJ QJ U'�j’0  h <Ú h,WD CJ OJ QJ Uh <Ú h,WD CJ OJ QJ  !j    h <Ú h,WD CJ OJ QJ U+�j0  h <Ú h†Rp CJ OJ QJ UaJ h <Ú h†Rp CJ OJ QJ aJ  %j    h <Ú h†Rp CJ OJ QJ UaJ h <Ú h†Rp 5�CJ OJ QJ h <Ú h†Rp CJ OJ QJ  !j    h <Ú h†Rp CJ OJ QJ U'�jª/  h <Ú h†Rp CJ OJ QJ U Ÿ  Ì  ñ      ö            ö            ö            ,                             É  kdz1  $$If   –l Ö            Öˆ hT¨°!È( ì                 T                                  T                                  ¼                
t  àÖ0   ÿ     ÿ     ÿ     ÿ     ÿ     ÿ  ö`'6ö  ö  Ö   ÿ   ÿ   ÿ   ÿ   ÿ   ÿÖ   ÿ   ÿ   ÿ   ÿ   ÿ   ÿÖ   ÿ   ÿ   ÿ   ÿ   ÿ   ÿÖ   ÿ   ÿ   ÿ   ÿ   ÿ   ÿ4Ö   4Ö 
l aöÔyt¡QA 	  $If   gd`iÕ        #  $  %  6  7  8  F  G  H  Y  Z  [  i  j  k  v  ~    †  ˆ  ‰  Š  ˜  óâÕÁâÕ³âÕŸâÕ³Ž�mŽc�c�S³âÕ                                     h <Ú h†Rp 5�CJ OJ QJ aJ h¡QA CJ OJ QJ  '�j$3  h <Ú h†Rp CJ OJ QJ Uh <Ú h†Rp CJ OJ QJ  !j    h <Ú h†Rp CJ OJ QJ U'�j°2  h <Ú h,WD CJ OJ QJ Uh <Ú h†Rp 5�CJ OJ QJ '�j<2  h <Ú h,WD CJ OJ QJ Uh <Ú h,WD CJ OJ QJ  !j    h <Ú h,WD CJ OJ QJ Uh <Ú h†Rp 5�OJ QJ    7  Z  ‰  °  Þ     ö            ö            ö            ö            ö            ö                                                                                                                                                                                                                                                                                                                                                                                                              	  $If   gd`iÕ  ˜  ™  š  ¯  °  ±  ¿  À  Á  Ý  Þ  ß  í  î  ï  ÿ                    *  ëÚÍ¿ÚÍ«ÚÍ¿ÚÍ—ÚÍŠ~pbÚÍNÚÍ                                '�j¶5  h <Ú hÏt8 CJ OJ QJ Uh�> h`iÕ 5�CJ OJ QJ h�> h�> 5�CJ OJ QJ h <Ú h†Rp 5�OJ QJ h <Ú h†Rp CJ OJ QJ  '�j€4  h <Ú h,WD CJ OJ QJ U'�j4  h <Ú h,WD CJ OJ QJ Uh <Ú h†Rp 5�CJ OJ QJ h <Ú h,WD CJ OJ QJ  !j    h <Ú h,WD CJ OJ QJ U'�j˜3  h <Ú h,WD CJ OJ QJ U        +  5            ,            #                           	  $If   gd`iÕ    „h^„hgd�>  É  kdô4  $$If   –l Ö            Öˆ hT¨°!È( ì                 T                                  T                                  ¼                
t  àÖ0   ÿ     ÿ     ÿ     ÿ     ÿ     ÿ  ö`'6ö  ö  Ö   ÿ   ÿ   ÿ   ÿ   ÿ   ÿÖ   ÿ   ÿ   ÿ   ÿ   ÿ   ÿÖ   ÿ   ÿ   ÿ   ÿ   ÿ   ÿÖ   ÿ   ÿ   ÿ   ÿ   ÿ   ÿ4Ö   4Ö 
l aöÔyt¡QA  *  +  ,  :  ;  <  I  J  K  Y  Z  [  h  i  j  x  y  z  „  …  †  ”  •  –     ¡  ¢  °  ±  ²  º  ¼  Â  Ã  Ä  ñàÓ¿àÓñàÓ«àÓñàÓ—àÓñàÓƒàÓñàÓoàÓeÓñY    h <Ú h,WD 5�OJ QJ h¡QA CJ OJ QJ  '�jú7  h <Ú h,WD CJ OJ QJ U'�j†7  h <Ú h,WD CJ OJ QJ U'�j7  h <Ú h,WD CJ OJ QJ U'�jž6  h <Ú h,WD CJ OJ QJ U'�j*6  h <Ú hÏt8 CJ OJ QJ Uh <Ú h,WD CJ OJ QJ  !j    h <Ú h,WD CJ OJ QJ Uh <Ú h,WD 5�CJ OJ QJ  "+  J  i  …  ¡  Ã  ö            ö            ö            ö            ö                                                                                                                                                                                                                                                                                                                                                                                                                               	  $If   gd`iÕ  Ã  Ä  é    ?  5            ,            ,            ,                            	  $If   gd`iÕ  É  kdn8  $$If   –l Ö            Öˆ h[\ÙuÀ!È( ó                                  }                 œ                 K                                 
t  àÖ0   ÿ     ÿ     ÿ     ÿ     ÿ     ÿ  ö`'6ö  ö  Ö   ÿ   ÿ   ÿ   ÿ   ÿ   ÿÖ   ÿ   ÿ   ÿ   ÿ   ÿ   ÿÖ   ÿ   ÿ   ÿ   ÿ   ÿ   ÿÖ   ÿ   ÿ   ÿ   ÿ   ÿ   ÿ4Ö   4Ö 
l aöÔyt¡QA  Ä  Å  Ó  Ô  Õ  é  ê  ø  ù  ú  û          $  %  &  1  2  3  4  ?  @  N  O  P  h  i  j  x  y  z  Š  ‹  îáÍîáîá¹îá¯á¡îá�îá€á€áîálîá¡îáXîá€  '�j ;  h <Ú h,WD CJ OJ QJ U'�jŒ:  h <Ú h,WD CJ OJ QJ Uh <Ú hË/Ð CJ OJ QJ  '�j:  h <Ú h,WD CJ OJ QJ Uh <Ú h,WD 5�CJ OJ QJ h�> CJ OJ QJ  '�j¤9  h <Ú h,WD CJ OJ QJ U'�j09  h <Ú h,WD CJ OJ QJ Uh <Ú h,WD CJ OJ QJ  !j    h <Ú h,WD CJ OJ QJ U "?  i  ’  ½  ¾  ö            ö            ö            ,                             É  kdè;  $$If   –l Ö            Öˆ h[\ÙuÀ!È( ó                                  }                 œ                 K                                 
t  àÖ0   ÿ     ÿ     ÿ     ÿ     ÿ     ÿ  ö`'6ö  ö  Ö   ÿ   ÿ   ÿ   ÿ   ÿ   ÿÖ   ÿ   ÿ   ÿ   ÿ   ÿ   ÿÖ   ÿ   ÿ   ÿ   ÿ   ÿ   ÿÖ   ÿ   ÿ   ÿ   ÿ   ÿ   ÿ4Ö   4Ö 
l aöÔyt¡QA 	  $If   gd`iÕ  ‹  ‘  ’  “  ¡  ¢  £  ¼  ½  ¾  ¿  Í  Î  Ï  ÷  ø  ù      	  $  %  &  4  5  6  W  X  f  óåÔÇ³ÔÇå§ÔÇ“ÔÇåÔÇÔÇånaMnaÔÇ          '�j’=  h <Ú h¥O CJ OJ QJ Uh <Ú h¥O CJ OJ QJ  !j    h <Ú h¥O CJ OJ QJ U'�j=  h <Ú hË/Ð CJ OJ QJ U'�jª<  h <Ú hË/Ð CJ OJ QJ Uh <Ú h,WD 5�OJ QJ '�jt;  h <Ú hË/Ð CJ OJ QJ Uh <Ú hË/Ð CJ OJ QJ  !j    h <Ú hË/Ð CJ OJ QJ Uh <Ú h,WD 5�CJ OJ QJ h <Ú h,WD CJ OJ QJ ¾  ø  %  V  W  ‹  ¹  ì  ö            ö            ö            ö            ö            ö            ö                                                                                                                                                                                                                                                                                                                                                                                             	  $If   gd`iÕ  f  g  h  Š  ‹  Œ  š  ›  œ  ¸  ¹  º  È  É  Ê  ë  ì  í  ò        $  %  &  1  ëÚÍ¿ÚÍ«ÚÍ¿ÚÍ—ÚÍ¿‹teZHeZ               #�j$@  h <Ú hÏt8 OJ QJ Uh <Ú h`iÕ OJ QJ  j    h <Ú h`iÕ OJ QJ Uh�> h`iÕ OJ QJ  h <Ú h`iÕ 5�OJ QJ h <Ú h,WD 5�OJ QJ '�jî>  h <Ú hË/Ð CJ OJ QJ U'�jz>  h <Ú hË/Ð CJ OJ QJ Uh <Ú h,WD 5�CJ OJ QJ h <Ú hË/Ð CJ OJ QJ  !j    h <Ú hË/Ð CJ OJ QJ U'�j>  h <Ú hË/Ð CJ OJ QJ U ì  í  î    „  5            0            0            '                     „h^„hgd¡QA    gd`iÕ  É  kdb?  $$If   –l Ö            Öˆ h[\ÙuÀ!È( ó                                  }                 œ                 K                                 
t  àÖ0   ÿ     ÿ     ÿ     ÿ     ÿ     ÿ  ö`'6ö  ö  Ö   ÿ   ÿ   ÿ   ÿ   ÿ   ÿÖ   ÿ   ÿ   ÿ   ÿ   ÿ   ÿÖ   ÿ   ÿ   ÿ   ÿ   ÿ   ÿÖ   ÿ   ÿ   ÿ   ÿ   ÿ   ÿ4Ö   4Ö 
l aöÔyt¡QA  1  2  4  5  C  D  E  [  \  ]  k  l  m  ƒ  „  …  “  ”  •  ¬  ­  ®  ¼  ½  ¾  ¿  ×  Ø  Ù  ç  è  é  ÷  ø  ù      õíÞÓÁÞÓõÞÓ¯ÞÓíÞÓ�ÞÓõÞÓ‹Þ€ÓõÞÓnÞÓõÞÓ\#�jÜB  h <Ú h`iÕ OJ QJ U#�jhB  h <Ú h`iÕ OJ QJ Uh <Ú hY5Ü OJ QJ  #�jôA  h <Ú h`iÕ OJ QJ U#�j€A  h <Ú h`iÕ OJ QJ U#�jA  h <Ú h`iÕ OJ QJ U#�j˜@  h <Ú h`iÕ OJ QJ Uh <Ú h`iÕ OJ QJ  j    h <Ú h`iÕ OJ QJ Uh�> OJ QJ  h <Ú h¥O OJ QJ $„  ø  f  È  TP   Q  0R  ÜR  àR   S  °S  vT  ÖT  U  ÀU  „V  †V  ˆV  äV  *W  .W  0W  4W  6W  :W  <W  @W  ö            ö            ö            ö            ö            ö            ö            ñ            ñ            è            ö            ö            ö            ö            ö            ö            ö            ö            ö            æ            æ            æ            æ            æ            æ            æ                                „Ð`„Ðgd`iÕ    gd`iÕ    „h^„hgd¡QA    	         .  /  0  @  B  C  Q  R  S  e  f  g  u  v  w  ƒ  …  †  ‡  •  –  —  ¢  ¤  ¥  ³  ´  µ  ¶  È  É  ×  ðåÚðåÈðåÚðå¶ðåÚðå¤ðåÚœðåŠðåÚ{Úi{aÚðå          h!« OJ QJ  #�j E  h <Ú h¥O OJ QJ Uj    h <Ú h¥O OJ QJ U#�j¬D  h <Ú h`iÕ OJ QJ Uh¡QA OJ QJ  #�j8D  h <Ú h`iÕ OJ QJ U#�jÄC  h <Ú h`iÕ OJ QJ U#�jPC  h <Ú h`iÕ OJ QJ Uh <Ú h¥O OJ QJ  h <Ú h`iÕ OJ QJ  j    h <Ú h`iÕ OJ QJ U $×  Ø  Ù  â              P  
P  P  ‚P  „P  ˜P  šP  œP  ¦P  ¨P  Q   Q  xQ  |Q  ~Q  ’Q  ”Q  –Q   Q  ¢Q  .R  0R  2R  íÞÓÈ¹È§¹¥“¹Ó¹È�¹“¹ÓÈÓy¹Èg¹“¹ÓyX                 j    h <Ú hY5Ü OJ QJ U#�jôF  h <Ú hÏt8 OJ QJ Uh¡QA OJ QJ  #�j~F  h <Ú hÏt8 OJ QJ U"j    h!« OJ QJ UmH nH u U#�jF  h <Ú hÏt8 OJ QJ Uj    h <Ú h¥O OJ QJ Uh <Ú h¥O OJ QJ  h <Ú h`iÕ OJ QJ  j    h <Ú h`iÕ OJ QJ U#�j”E  h <Ú h`iÕ OJ QJ U       _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  1 .     L i s t   d i a g n o s i s :     _ _    F O R M T E X T           _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  2 .     L i s t   a l l   m e d i c a t i o n s ,   t i m e ,   a n d   d o s a g e :          F O R M T E X T           _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _     F O R M T E X T           _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  	  I I I .   R E S O U R C E   P A R E N T   C H E C K L I S T :  ( R e s o u r c e   p a r e n t ,   p l e a s e   p r o v i d e   t h e   f o l l o w i n g   t o   t h e   r e s p i t e   p r o v i d e r )     F O R M C H E C K B O X         P l a c i n g   F o s t e r   P a r e n t   h a s   n o t i f i e d   t h e   c h i l d ' s   c a s e   m a n a g e r   o f   r e s p i t e   d e t a i l s ,              d a t e s ,   R e s p i t e   P r o v i d e r ,   a n d   p h o n e   n u m b e r     F O R M C H E C K B O X     	 M e d i c a i d   n u m b e r     F O R M C H E C K B O X     	 H e a l t h   i n f o r m a t i o n ,   s o c i a l   w o r k e r   i n f o r m a t i o n ,   c h i l d   i n f o r m a t i o n     F O R M C H E C K B O X     	 I n v e n t o r y :   c l o t h i n g ,   s p e c i a l   e q u i p m e n t ,   e y e   g l a s s e s ,   t o i l e t r i e s   e . g .   t o o t h b r u s h    _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 	 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _    R e s o u r c e   P a r e n t ' s   S i g n a t u r e 	 	 D a t e                	 	   	 	     C D - 1 1 0   ( 1 / 0 9 )                                                                                                                                                 2R  FR  HR  JR  TR  VR  ¢R  ÚR  àR  úR   S  2S  °S  ²S  ÎS  ÐS  ÒS  ÖS  rT  tT  vT  „T  ¼T  ¾T  ÖT  ØT  ôT  õãÔÂÔ·õ·«Ÿ’…v·dv\·\·Q·Q·v·                            h <Ú h‘B9 OJ QJ  h!« OJ QJ  #�jàG  h <Ú hÏt8 OJ QJ Uj    h <Ú h`iÕ OJ QJ Uh�> h`iÕ CJ OJ QJ  h�> h‘B9 CJ OJ QJ  h <Ú h`iÕ 5�OJ QJ h <Ú h‘B9 5�OJ QJ h <Ú h`iÕ OJ QJ  "j    h!« OJ QJ UmH nH u j    h <Ú hY5Ü OJ QJ U#�jjG  h <Ú hÏt8 OJ QJ Uh <Ú hY5Ü OJ QJ ôT  öT  øT  U  U  8U  :U  <U  ÀU  ÂU  ÞU  àU  âU  üU  „V  †V  ˆV  äV  ôV  *W  ,W  0W  2W  6W  8W  <W  >W  BW  pW  rW  tW  íÞÓÞÓÁÞÓÞÓ¯Þ¤Óœ‘Ó¤Ó‰…‰…‰…‰…�…Ó                                                                                                        hêsL  hŽaù  j    hŽaù Uh <Ú h¡QA OJ QJ  h`iÕ OJ QJ  h <Ú h‘B9 OJ QJ  #�j@I  h <Ú h`iÕ OJ QJ U#�jÊH  h <Ú h`iÕ OJ QJ Uh <Ú h`iÕ OJ QJ  j    h <Ú h`iÕ OJ QJ U#�jTH  h <Ú h`iÕ OJ QJ U @W  BW  HW  JW  nW  pW  rW  tW  ý            û            ý            ó            ý            ý            ê                                                                                                                                                                                                                                                                                                                                                                        „h^„hgd¡QA   $a$gd¡QA       2 1�h:p¡QA °Ð/ °à=!°Ð"°Ð#�°$�°%°  °Ð°Ð�Ð                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Z!  D d n n   
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ð      
  S ð   A      �  ¿   ÿ     ð      €b ðÄ   Š´"…UâJEˆâ"jqÿ        D     § nð˜   Š´"…UâJEˆâ"jqÿ‰PNG
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 ZÈZK«aýE“�øç‰¤Ö\94Y×øû1<CcˆvºMWW1{:¯åîÿ£;ÂQip�,ó¨\k�¥y*Écggé¼6®¥¢	m¿‘¨˜JN¡=.[&YÀËcÓDƒŠŽDdM¯&D_ÛCï‰§Sñ®ˆÎRéõéàl5‹uÔF¹î>i<�9ÔžÕ6?wèwØy2žLvôÄØ;µí�Ùr—ÒY5“A\M¦ì#ÔZ››“,²t÷^û­&Ÿµbx¨·[�|d§+ÂQÌéÖñST8çaaœ™Ö�ôâÒ¸×CœýmjD÷M¶$þ2¸"©(S|¤Ž¦Ã67¼C0\ÍQ-igdË+¾¥ªãÜ½áüµl�1$ér¥ã¨á5>žŒ&Ò×…Ò+Ý˜Î„Ènú.õzxZƒ¸’Ì>9€:&9“›VB!ü}Ù#—üDm=FQìf]ádØÙ„ÉÅ¯\áµ!éBíi=¢ÍýúkÐãx°CÃ ;ÖÁ#çUY$ï†]”4ÓŒ‰�I€«?^š½ß÷Þ¢wä�Ê/€UÈ6ß74:.„ÖF<Íy"®[Ö@ý~ë§Ýå��°½µµði‹@¹–fj÷ÿ'‘o‘±ÎLÇ7ÓvÌIÆ!9àÀ>2ÿy¹íµ<jÐæ5fsw®JÇÕ±dÈ§zkL¹}‹ÚÈøÕ†=¯ôbjA7]Jºo�=„ãiæŠ×ùÆ¡Ömæ�öø¹´ð¢{êeËèc³‹<&ÐHÉ\Û€Oìt5÷éþÞæÝ}ß	é]ÉDR�±È¢konº6�¤œL°M×Þ3®á˜é½ãZBã ÌÄÛ €•‡Š&Éªjù±Ù…”ÞADî�=eƒZ¡Hi¯–Üéµ.f©HºvTBÕý,nÓ[: �z½¤ôÛ.4ÝB2‡ÿ…+:Xi™T„ì± ê:ûù|5mjAY8²u3�ãï•Mß‘±pi8¢ùuE{íýÚ‹¿·Û~¶ÈØï½Q[i ™bL´uî·ÜZTç,‰û¤Á}ÎZ�ßë;C}ƒö]‡!5E®<M’ÛÒY/'3KWÎ??yñ9§_ó�±>Ì†&bhsØG�ÁoI¼ÍgRï{uk¢Ít_V9…ý�^Ê7Òª0¹fï¡G˜ËVÎÂ# XMªv:~ZOö‡Ú©¼¢Ç{a_hST"Ž,ŒGhÓå$p.štõ~]ÒV2	‚CFT^u¬;õHàU[Ÿ—ƒe‹ÌGð²�Ú®Œ]r�ò¢ìÛ×™Â3˜Ÿ–÷kÞx'ÔIŽ  ã$9Z¶¬‡Ô›½°O™qI¸ª<ðdtÎ¿.dÂ5„=ÊÑÙšoQƒÜÝ#--dä5ç†ýKˆ~�kFpM×õ4¢8)-n ¹™î}œ•&¡¹¼|~`'|”Ûn‘ú‚§9¨€G*jRâq¥ÁÚÔ™knîÌ¶Ïvù¼ØgP4�˜�.(QùÑf§~”¶)8t7>m€ñYópo;@ŸóD™»P‰ …c~í^hÐÒ³#)Íë×4ÿùK®‘ã£ W\´y&šø!¾„ÛÇk$'á+eÜùT0“>«óõ-¢‹kŽAÀ¾@è´ã‰YJe¡	)ËT‘{ÿ (=ádÞÓmÊÍby]ªÉçŒ²AŸu¸ÝzŸpÝyvÏ£F“[î†šOX£A§Ÿ&qs°Æ¬ül`&a^W0;( )Ô@'MÚ$ÚçMê¥ü*ª3½¢yNY9TÁ´êI\g¶Ý*†;ë–_|Î5aù,K>—‡:!ºÉrÍxUSwÈðNÂw¡íSÔd‚G²W`^eõ&åL…ŠÊu¨ìª–I¯_]‚0Q×¦¢2ÃÛÁrCc÷-Â{Da *‰W*åöÁÙÁ‡¤ðA�ä$}•í��Ë­4õ¾š6ÍufzcÍÞ¡ù”Â)ûLþîö{¦„(.iÈL4pò‹<dš_eEyóÆ‚½	‚3S>A¹|"G7´´ö
Ad�Õ×ùšŠ «GðQšÆeò�‡/úHN.WúÊ*+¶�	ñˆzêœ{�”‚ÐÎoßxå9C	pzÏÂ3¼H9SöññÉ%@+¶ÔÔgöÉ±ÁçjÉ1–Jû^ù¾ª±MBÔ"S¿ž™5«ï¨)XÍÛ/9éÜx�«îubçÎ«':R:¶ÉB5F@Ÿ&¯�ý?‡
S1eJEæÞÂÖ»`,¨}±ˆ=ÜŽêÁp\ÑÃÈrY´[ŒïZ_t�™â•Èy�$ísù¢I_ueeùØ”ÒÌ<Ã(´$S“#Žb•Ç%<KŸÁ'#5P,ò×Ò)ÐsöùyOÆ|@hLYYkìÉ1nGÏª®T×ªXOüÑˆg3ÇGKŠ‹¤î›lÌÀØ¤þ±ÇŒ>hZ $°¢ì`&SsõXfÊ¶M£;
#ãrÆG¶??R_c‹áC0ÉŒ•ÉG*LÒ&:(_jÉœ4ÁÊŠŠS2õ%–ÌÕ°ßÒLii}i‰År�‰êàb‹¥¤¤>“™²¯¼Ò”Ú—cãGMÏ`°¼lÊX=`jj,ÅÅÅ÷[Š «©¥õ™1“‹&¿¬Ô>ÌR<é’·VÁ*úËËÊÇ ÅúR¬’RJ�++3¹8AÙW¦mÂ•È|7_m­n–L-/+;Ý3¿¦LÉ”M);PQ>�%eö•Íü˜ŽÊ”j®VV °åò[.üc‚.ìKéÆ§zm³«Œ'0«*«*«‘«âA0¼R5>0¹ø��;ÂTÊã9O¤rIóX§©ÿ=‘}¡cðìØ·”Õ—#ëÿÞÝiÅ‰d¨»    IEND®B`‚r $$If   –l !v h5Ö /5Öå"#v /#vå":V –l ”
t  àö(6ö  ,Ö 5Ö /5Öå"aöl yt¡QA t   D                                                               ÿÿÿÿ  <    T e x t 1                           t   D                                                               ÿÿÿÿ  	    T e x t 2                           j   D                                                               ÿÿÿÿ  	                               t   D                                                               ÿÿÿÿ      T e x t 4                           j   D                                                               ÿÿÿÿ                                 t   D                                                               ÿÿÿÿ      T e x t 5                           t   D                                                               ÿÿÿÿ      T e x t 6                           t   D                                                               ÿÿÿÿ      T e x t 7                           t   D                                                               ÿÿÿÿ      T e x t 8                           v   D                                                               ÿÿÿÿ      T e x t 1 0                             D d                    �$ ƒ                                 ðz   ²
ð      
  S ð0   A   Á      ¿   ÿ   B D 1 0 2 1 9 _   S "ñ   “    ”   •2   –l&  ¿    ð     €b ð6  ª²Â”ùÔ~¼è2¾b§ÿ      ˆ&    § nð
  ª²Â”ùÔ~¼è2¾b§ÿ‰PNG

   IHDR  o      9Ë   tEXtTitle default_horizontal_line÷ÍçÐ   PLTEÀÀÀÌÌÌfff   'a¹¿       <ã <ã `‹ lŸG ˜Ž  bŽÃDÏTÎ� 9@_˜	             <ã pÎ� É@_                  ÐÎ� ;@_           Ï� Ž_  jÏ� ˜	                       @_	    Ï� Ž_  `‹ „Î� Ï� ÊøH_    ìÎ� Æ@_    ˜	     @_	    Ï� Ï� P@_‚-@_    ‹@_Ž_  x { TÏ� +øH_ÿÿÿÿ8Ï� c6÷¿˜	             Ç)h_?  LÏ� #÷¿    ”]�™(ù¿y÷¿ˆ_   Ñ� .÷¿Ç)h_    h_o)    F  Æ_ .; ç  ?''  o)?''Ì_ú;       D@_           ú;       ¸_4zÿÿo)Ì_A<ÿÿo)    o)¬ ìM`   D@_ç‚Ï         ˜	¬  ìM      ð?@
xÿ           xfà³ô �³ô        pe ìM   ?  £ ,i9  ”]�™(¬ T`Nd· ìM ?G h`·      ìM À`  o    ?+÷¿?''Ü`ú;   ™²  ¼·   Ñ� È'÷¿Ç"ö¿ p� P]�              Ô{     äÐ� jb¹¿€  � f¤qã † f¤qã     ê   HÑ� óç f¤qã ê   ¬ f¤qã ê   à³ô |s¦   bKGD ˆH   cmPPJCmp0712   H s¼   IDAT8Oc`£!@¿``£!@¿  ÉN3îè   @tEXtComment FILE IDENTITY
Created or modified by
ASHOK KUPPUSAMY
S30Ã    IEND®B`‚t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         À $$If   –Ô!v h5Ö ì5ÖT5Ö5ÖT5Ö5Ö¼#v ì#vT#v#vT#v#v¼:V –l 
t  àö`'6ö  5Ö ì5ÖT5Ö5ÖT5Ö5Ö¼aöÔyt¡QA t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         À $$If   –Ô!v h5Ö ì5ÖT5Ö5ÖT5Ö5Ö¼#v ì#vT#v#vT#v#v¼:V –l 
t  àö`'6ö  5Ö ì5ÖT5Ö5ÖT5Ö5Ö¼aöÔyt¡QA t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         À $$If   –Ô!v h5Ö ì5ÖT5Ö5ÖT5Ö5Ö¼#v ì#vT#v#vT#v#v¼:V –l 
t  àö`'6ö  5Ö ì5ÖT5Ö5ÖT5Ö5Ö¼aöÔyt¡QA t   D                                                               ÿÿÿÿ     C h e c k 6                         t   D                                                               ÿÿÿÿ     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         À $$If   –Ô!v h5Ö ó5Ö5Ö}5Öœ5ÖK5Ö#v ó#v#v}#vœ#vK#v:V –l 
t  àö`'6ö  5Ö ó5Ö5Ö}5Öœ5ÖK5ÖaöÔyt¡QA t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         À $$If   –Ô!v h5Ö ó5Ö5Ö}5Öœ5ÖK5Ö#v ó#v#v}#vœ#vK#v:V –l 
t  àö`'6ö  5Ö ó5Ö5Ö}5Öœ5ÖK5ÖaöÔyt¡QA t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         À $$If   –Ô!v h5Ö ó5Ö5Ö}5Öœ5ÖK5Ö#v ó#v#v}#vœ#vK#v:V –l 
t  àö`'6ö  5Ö ó5Ö5Ö}5Öœ5ÖK5ÖaöÔyt¡QA t   D                                                               ÿÿÿÿ     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         t   D                                                               ÿÿÿÿe     C h e c k 6                         v   D                                                               ÿÿÿÿ  2    T e x t 1 1                           v   D                                                               ÿÿÿÿ  A    T e x t 1 2                           v   D                                                               ÿÿÿÿ  <    T e x t 1 3                           v   D                                                               ÿÿÿÿ  F    T e x t 1 4                           t   D                                                               ÿÿÿÿ     C h e c k 9                         v   D                                                               ÿÿÿÿe     C h e c k 1 0                         v   D                                                               ÿÿÿÿe     C h e c k 1 2                         v   D                                                               ÿÿÿÿe     C h e c k 1 3                                                                                                   †   œ                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            @  @ñÿ @    `iÕ    N o r m a l       CJ _HaJ mH	sH	tH	                  D A òÿ¡ D          D e f a u l t   P a r a g r a p h   F o n t     R i@óÿ³ R          T a b l e   N o r m a l    ö  4Ö 
l 4Ö   aö      ( k ôÿÁ (           N o   L i s t          4 @ ò 4   `iÕ    H e a d e r     Æ àÀ!   4  @ 4   `iÕ    F o o t e r     Æ àÀ!   H ™  H   y�    B a l l o o n   T e x t      CJ OJ QJ ^J aJ j š@³ #j   †Rp   
 T a b l e   G r i d   7 :V Ö0   ÿ     ÿ     ÿ     ÿ     ÿ     ÿ           È    ^   ÿÿÿÿ       .   U   i   j   k   „   Ò     ’  Ö  5  7  O  P  w  ˆ  ¥  Æ  á       <  =  ^  €  Ÿ  Ì  ñ      7  Z  ‰  °  Þ         +  J  i  …  ¡  Ã  Ä  é    ?  i  ’  ½  ¾  ø  %  V  W  ‹  ¹  ì  í  î    „  ø  f	  È	  8
  ž
  &  |  ~  ž  æ  I  y  ›  î  P  Q  R  €  £  ¥  ¦  ¨  ©  «  ¬  ®  ¯  ²  ³  Å  Æ  É  ©    0       €   €  Ð      ©    0       €   €  Ð      ©    0       €   €  Ð      ©    0       €   €  Ð      ™    0       €   €  Ô      ˜    0       €   €          ˜@   0       €   €          ˜    0       €   €          ˜    0       €   €          ˜    0       €   €          ˜    0       €   €          ˜    0       €   €          ˜@   0       €   €          ˜@   0       €   €          ˜@   0       €   €          ˜@   0       €   €          ˜@   0       €   €          ©@   0       €   €  ¨      ©@   0       €   €  ¨      ©@   0       €   €  ¨      ©@   0       €   €  ¨      ©@   0       €   €  ¨      ©@   0       €   €  ¨      ™@   0       €   €  ¬      ©@   0       €   €  Ð      ©@   0       €   €  Ð      ©@   0       €   €  Ð      ©@   0       €   €  Ð      ©@   0       €   €  Ð      ©@   0       €   €  Ð      ™@   0       €   €  Ô      ©@   0       €   €  Ð      ©@   0       €   €  Ð      ©@   0       €   €  Ð     ©@   0       €   €  Ð      ©@   0       €   €  Ð      ©@   0       €   €  Ð      ™@   0       €   €  Ô      ˜@   0       €   €          ©@   0       €   €  Ð      ©@   0       €   €  Ð      ©@   0       €   €  Ð      ©@   0       €   €  Ð      ©@   0       €   €  Ð      ©@   0       €   €  Ð     ™@   0       €   €  Ô      ©@   0       €   €  Ð      ©@   0       €   €  Ð      ©@   0       €   €  Ð      ©@   0       €   €  Ð      ©@   0       €   €  Ð      ©@   0       €   €  Ð      ™@   0       €   €  Ô      ©@   0       €   €  Ð      ©@   0       €   €  Ð      ©@   0       €   €  Ð      ©@   0       €   €  Ð      ©@   0       €   €  Ð      ©@   0       €   €  Ð      ©@   0       €   €  Ð      ™@   0       €   €  Ô      ˜@   0       €   €          ˜@   0       €   €          ˜@   0       €   €          ˜@   0       €   €          ˜@   0       €   €          ˜    0       €   €          ˜    0       €   €          ˜    0       €   €          ˜    0       €   €          ˜    0       €   €          ˜@   0       €   €          ˜@   0       €   €          ˜@   0       €   €          ˜    0       €   €          ˜    0       €   €          ˜@   0       €   €          ˜@   0       €   €          ˜@   0       €   €          ˜    0       €   €          ˜    0       €   €          ˜@   0       €   €          ˜    0       €   €          ˜@   0       €   €         X‘ 0 0                   Ÿ˜@   0       €   €         X‘ 0 0                   Ÿ˜@   0       €   €         X‘ 0 0                   Ÿ˜@   0       €   €         X‘ 0 0                   Ÿ˜@  0       €   €         ˜@   0       €   €          ˜@  0       €   €          ˜@   0       €   €        € X‘ 0 0                 „Ÿ    É  š           €   €       €              	                  #   #   #   &      Œ	   
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  <  Ÿ       +  Ã  ?  ¾  ì  „  @W  tW                             !   #   %   .      rW     “   Ÿ   ¥   »   Ç   Í   ð   ü       "  (  .  :  @  P  \  b  x  „  Š  ·  Ã  É  å  ñ  ÷        ˆ  ˜  ¥  µ  Æ  Ö  á  ñ         -  =  M  ^  n  €  �  Ÿ  ¯  Ì  Ü  ñ      $  7  G  Z  j  ‰  ™  °  À  Þ  î      +  ;  J  Z  i  y  …  •  ¡  ±  Ä  Ô  é  ù    %  ?  O  i  y  ’  ¢  ¾  Î  ø    %  5  W  g  ‹  ›  ¹  É    %  4  D  \  l  „  ”  ­  ½  Ø  è  ø  	  	  /	  B	  R	  f	  v	  †	  –	  ¤	  ´	  È	  Ø	  
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  [
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  &  2  8  æ  ö  y  ‰  ›  «  î  þ  È  Fÿ•€Fÿ•€Fÿ•€Fÿ•€Fÿ•€Fÿ•€Fÿ•€Fÿ•€Fÿ•€Fÿ•€G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$G•$Fÿ•€Fÿ•€Fÿ•€Fÿ•€G•$G•$G•$G•$ÿÿ    T e x t 1  T e x t 2  T e x t 4  T e x t 1 5  T e x t 5  T e x t 6  T e x t 7  T e x t 8  T e x t 1 0  T e x t 1 1  T e x t 1 2  T e x t 1 3  T e x t 1 4  C h e c k 9  C h e c k 1 0  C h e c k 1 2  C h e c k 1 3 “   »     -  P  x  ·  å    
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  
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  %  9  ž  ž  ù  ù  G  H  O  O  P  Q  ¢  £  £  ¥  ¥  ¦  ¦  ¨  ©  «  ¬  ®  ±  ³  Ä  É                                                                                               £  £  ¥  ¥  ¦  ¦  ¨  ©  «  ¬  ®  ¯  Æ  É                         å          �> NK ± L6 Ït8 ‘B9 ¡QA ,WD êsL ¥O 88\ †Rp #O} y� Hn� Ó-• ²`¦ 8\¨ !« þ?­ WÊ Ë/Ð `iÕ  <Ú Y5Ü eÝ ’qâ ý]ò Žaù        i   j   ˆ  ¥  Æ  á       <  =  ^  €  Ÿ  Ì  ñ      7  Z  ‰  °  Þ         +  J  i  …  ¡  Ã  Ä  é    ?  i  ’  ½  ¾  ø  %  W  ‹  ¹  ì  í  É          –                 ž              ž              –                 ž              ž              –  ÿ@      ¥   P‹                 4             
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   D     P     \     h     t     |     „     Œ     ä        CHILD INFORMATION FORM                  tattv1s                           cd110.dot         roetuwb       2         Microsoft Office Word   @    FÃ#    @     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Department of Social Services                 �     '                                     CHILD INFORMATION FORM            Title                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              	   
                                                                      !   "   #   $   %   &   '   (   )   *   +   ,   -   .   /   þÿÿÿ1   2   3   4   5   6   7   8   9   :   ;   <   =   >   ?   @   A   B   C   D   E   F   G   H   I   J   K   L   M   N   O   P   Q   R   S   T   þÿÿÿV   W   X   Y   Z   [   \   ]   ^   _   `   a   b   c   d   e   þÿÿÿg   h   i   j   k   l   m   þÿÿÿo   p   q   r   s   t   u   þÿÿÿýÿÿÿx   þÿÿÿþÿÿÿþÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿR o o t   E n t r y                                              ÿÿÿÿÿÿÿÿ   	     À      F            @œå�GwÉz   €       D a t a                                                         
 ÿÿÿÿÿÿÿÿÿÿÿÿ                                    0   ¶I      1 T a b l e                                                            ÿÿÿÿ                                    U   7!      W o r d D o c u m e n t                                                ÿÿÿÿ                                        4^       S u m m a r y I n f o r m a t i o n                           ( ÿÿÿÿÿÿÿÿÿÿÿÿ                                    f           D o c u m e n t S u m m a r y I n f o r m a t i o n           8    ÿÿÿÿÿÿÿÿ                                    n           C o m p O b j                                                   ÿÿÿÿÿÿÿÿÿÿÿÿ                                        q                                                                           ÿÿÿÿÿÿÿÿÿÿÿÿ                                                   þÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿ þÿ
  ÿÿÿÿ	     À      F   Microsoft Office Word Document 
   MSWordDoc    Word.Document.8 ô9²q                                                                                                                                                                                                                                                                                                                                                                                                                           