Epstein Secrets

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)

with their current Florida school, fill in boxed areas below and complete Part A-2 on the reverse side of this form. • For additional information: Sec Immunization Guidelines for School and Child Care Facilities for information and instructions on form completion and immunization requirements. Guidelines are updated annually and arc available from the local

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

with their current Florida school, fill in boxed areas below and complete Part A-2 on the reverse side of this form. • For additional information: Sec Immunization Guidelines for School and Child Care Facilities for information and instructions on form completion and immunization requirements. Guidelines arc available from the local county health department.

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

with their current Florida school, fill in boxed areas below and complete Part 42 on the reverse side of this form. • For additional information: Sec Immunization Guidelines for School and Child Care Facilities for information and instructions on form completion and immunization requirements Guidelines arc available from the local county health department.

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

with their current Florida school, fill in boxed areas below and complete Part A-2 on the reverse side of this form. • For additional information: Sec Immunization Guidelines for School and Child Care Facilities for information and instructions on form completion and immunization requirements. Guidelines arc available from the local county health department.