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FYING INFORMATION: Youth s Name DOB: Address Town State Zip Previous Address Town State Zip Height Weight Eye Color Scars, Marks, Piercings, Tattoos: Complexion Birth place Current religious/cultural practices Ethnicity (Check all that apply) American Indian/Alaskan Native Asian Black or African American Native Hawaiian/ Other Pacific Islander White/Caucasian Mother s Name: Birth mother Address Town Place of Work: Father s Name Birth Father Address Town Place of Work: ABSENT PARENT: Name:.

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