Epstein Secrets

parent is in the uniformed services of the United States. O 0 If E. is YES, is the parent on active duty? Check service below: 0 Air force 0 Army 0 Coast Guard 0 Mannes 0 National Guard 0 Navy 9) NAME OF SC1400L TRANSFERRING FROM (22) LAST GRADE LEvEt. (23)LAST PUBLIC SCHOOL ATTENDED W4 PALM BEACH GOWN 1

nic Name: (Print or stamp) Expiration Date: (t5 days after next immunization appointment) Physician or Address: Authorized Signature: Date: Permanent Medical Exemption PART C For medically contraindicated immunizations, list each vaccine and state valid clinical reasoning or evidence for exemption: DOE Code 3 I c

med services of the United States. 0 Yes a No If "E" Is YES, Is the parent on active duty? 0 Yes 0 No (check service below) 0 Air Force 0 Army 0 Coast Guard 0 National Guard 0 Navy 0 Marines 2. Preschool Enrollment Information (Check each program attended. Indicate with an asterisk fl the program you

Clinic Name: Expiration Date: (Print or sump) (15 days after next immunization appointment) Physician or Address: Authorized Signature: Date: Permanent Medical Exemption PART C For medically contraindicated immunizations, list each vaccine and state valid clinical reasoning or evidence for exemption: DOE Code 3 - -

0 C. Chapter 1 0 S. Subsidized Child Care 0 O. Other 0 0 If E. is YES, is the parent on active duty? Check service below: 0 Air Force • Army 0 Coast Guard 0 Marines 0 National Guard 0 Navy (17) ISIHE STUDENT A SNORE PARENT? NO 0 YES 0 NO Om CURRENT GRADE LEVEL 07 4TRANSEEWINEORMATION ;a6„...-Waif

ic Name: 05•days after next immuilization.appoiutrnent) (Print or stamp) . . _ . . . • Physician or Address: Authorized Signature: Date: Permanent Medical Exemption PART C For medically contraindicated immunizations, list each vaccine and state valid clinical reasoning or evidence for exemption: DOE Code 3 I c

ion 0 C. Chapter 1 0 S. Subsidized Chid Care 0 0. Other 0 0 If E. is YES, s the parent on active duty? Check service below' 8 Air Force D Army Coast Guard 0 Marines 0 National Guard 0 Navy 17) iS THE STUDENT A SI LE PARENT, NO 0 YES 0 NO (IL) CURRENT CRAM LEVEL 08 TRANSFER INFORMATION (zo)C01. OR

rvice Address: Riviera Bea L 33404 Phone: Expiration Date: (IS days after next Physician or Authorized Signatu A. 41/21-4goo/ w 7 3.0) •, Permanent Medical Exemption PART C For medically contraindicated immunizations, list each vaccine and state valid clinical reasoning or evidence for exemption: DOE Code 3 / c

med services of the United States. 0 Yes a No If "E" Is YES, Is the parent on active duty? 0 Yes 0 No (check service below) 0 Air Force 0 Army 0 Coast Guard 0 National Guard 0 Navy 0 Marines 2. Preschool Enrollment Information (Check each program attended. Indicate with an asterisk fl the program you

Clinic Name: Expiration Date: (Print or sump) (15 days after next immunization appointment) Physician or Address: Authorized Signature: Date: Permanent Medical Exemption PART C For medically contraindicated immunizations, list each vaccine and state valid clinical reasoning or evidence for exemption: DOE Code 3 - -