{"text":"of this torm to SWSG \n. Pleasa refer to notes Issued for 1\/4\/78 \nReferencamumber 19 | . | {1 ]| o) Salols \nSex (1 =~boy, 2~girl) 10 i \nDate of birth (D.M.Y.) 116 | |05 |50 \nA. PERSONAL INFORMATION co. 1 [3] \n1 Reference number2-10 [_.] {JI \".I LI u' QI o]o s \n2 Sex (1=boy, 2= gir) n | \n3 Date of birth (D.M.Y.) 1217 [ 3 {013 |12 \n4 Physical-handicap or mental disorder 18 \n5 Social Work Department 1820 | [ \n6 AreaCode 212 | A (\u2122 \nB. FAMILY INFORMATION (at date of admission) \n1 Household composition code \n- \n2 District code of residence \n23 \n2425 | \n3 Employment code of father 26 \n&4 Employment code of mother 27 \n28 \n29 \n30 \n5 Number of children in household {9 or over, enter 9) \n6 Birth order of child (9 or over, enter 9) \n7 Number of siblings in care or under supsrvision \n(9 or over, enter 9) \nC. PRESENT PERIOD OF CARE OR SUPERVISION \n1 D-te of admission (D.M.Y.) 31-36 Z li - l;_{ s ? \n2 Hvason for admission-Statute L 3738 [~ |\\ \nPrimary reason within statute 3940 2 \\ \n3 Accommedation-Type 142 |7 I\\ \nDistrict code 345 | [0 \ne @) %0 519 o B0 \n4 Immediate (short tetrm) placement (i applicable) \nType of accommodation \u00a71-52 \u2014_IN \nDistrict code 5384 [y |, \n8 Number of previous periods of care or supervision 8 | \n(it none, enter O; if 9 or over, enter 9) \nSPARE BOXES \nfor use, see notes 66-67 \n58-59 \newsLI 11 \n= D Aled AL OACAYTY \nsuma\ufb01zaELr-J\u201d\\JCI'ilal%l [ ] \nInitials 29 \n1=new admission 3=transfar \n-30 \nType of admission | 2=re-admission 4\u2014amendment ) \npunch-repreduce columns 2-10 \nPREVIOUS PERIODS OF CARE OR SUPERVISION \n{most recent first) \n1 Date of admission (D.M.Y.) t1-16 \nReason for admission-Statute \nPrimary reason within statute \nDate of discharge (D.M.Y.) 21-26 \nReason for discharge \n2 Date of admission (D.M.Y.) 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