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MILY PHYSICiAN (46) PHYSCIAN PHONE (48) Does your child currently have health Insurance? 0 YES 0 NO If YES. Indicate (47) HOSPITAL PREFERENCE p Medicaid 0 Private • Healthy Kids, l60 Care ID interested In receiving information PARENTS/GUARDIAN'S OTHER CHILDREN IN PALM BEACH COUNTY SCHOOLS (49)

El Other This page has been updated OV DATE: 4a97 a5- BY: DATE: PBSD 0269 (REV. 1/88) EFTA01709618 FLORIDA CERTIFICATION OF IMMUNIZATION Legal Authority: FLORIDA STATUTES 232.032, s. 10D-3.088, F.A.C. and s. 10M-12, F.A.C. LAST NAME PARENT OR GUARDIAN FIRST MI DOB MCYDAAR Child's SS# (optional)

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14 Form 3040 which easy be used) Mock Plumbot. 5744400.3040-2) Authorized Signature-- Date EFTA01709711 FLORIDA CERTIFICATION OF IMMUNIZATION Legal Authority: sections 232.032, 402.305, 402.313, Florida Statutes; rules 64D-3.011, 65C-22.006, 65C-20.011, Florida Administrative Code LAST NAME PARENT OR GU

Y PHYSICIAN (46) PHYSICIAN PHONE (48) Does your child currently have health insurance? MI YES 0 NO If YES, indicate: (47) HOSPITAL PREFERENCE 0 Medicaid 0 Private 0 Healthy Kids/kQd Care 0 Interested In receiving information ASWALOA491.4:04iiit lit filierAlaffiblikr0S-1-101)1; . .. (49) NAME CF

WL MRS- /I ion 3040, Mar 9 (Stock Weber: 5744.000.3040-2) Mod JO SPI *Ostlers) ---4110ato EFTA01709961 FLORIDA CERTIFICATION OF IMMUNIZATION Legal Authority: FLORIDA STATUTES 23L037., a. 20D4.088, F.A.C. and s. 10M-12, P.A.C. LAST NAME PARENT OR GUARDIAN FIRST MI DOB MOIDNYR Child's SS* (optional)

0 Yes (Permission is void through grade 5.) 0 No 6. Does your child currently have health Insurance? ;Yes Q No p If YES, check insurance plan: 0 Medicaid 0 Healthy Kids/Kid Care IXPrivate K Interested in receiving information 7. All new students to Palm Beach County are required to answer the followin

TY MIAMI FL 33188.0001 NEW Charges Past Due Total Now Due AUG 21 2003 $228.20 EFTA01710059 • • I' FLORIDA CERTIFICATION OF IMMUNIZATION Legal Authority: sections 232.032, 402.305, 402.313, Florida Statutes; rules 640-3.011.65C-22.006, 65C-20.01I, Florida Administrative Code LAST NAME PARENT OR GUA

um fluoride program (Permission is valid (hmugh grade 6) YES (27) Does your child currently have health insurance? 0 YES 0 NO If YES, indicate: 0 Medicaid 0 Healthy Kids/Kid Care 0 Private (29) NOME LANGUAGE SURVEY (Chock so that Appy) 0 A language other than English Is used in the home. 0 The stude

I PHYSICIAN OR CONIC NAME (PLEASE PRINT) JATELY IMMUNIZED AGAINST 'DANCE. -//,1/2,73 DATE EFTA01710101 FLORIDA CERTIFICATION OF IMMUNIZATION Legal Authority: FLORIDA STATUTES 232.032, a 10D-3.088, F.A.C. and S. 10M-12, F.A.C. ATE PARENT OR GUARDIAN FIRS I MI DOB moinAnta Child's 5Stt (optional) ST

0 Yes (Permission is void through grade 5.) 0 No 6. Does your child currently have health Insurance? ;Yes Q No p If YES, check insurance plan: 0 Medicaid 0 Healthy Kids/Kid Care IXPrivate K Interested in receiving information 7. All new students to Palm Beach County are required to answer the followin

TY MIAMI FL 33188.0001 NEW Charges Past Due Total Now Due AUG 21 2003 $228.20 EFTA01727112 • • I' FLORIDA CERTIFICATION OF IMMUNIZATION Legal Authority: sections 232.032, 402.305, 402.313, Florida Statutes; rules 640-3.011.65C-22.006, 65C-20.01I, Florida Administrative Code LAST NAME PARENT OR GUA