Epstein Secrets

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

e either physician documented or parental recall (fork' i year) for school attendance as documented on the reverse side of this form. Physician or Clinic Na Physician or (Print or stamp) Authorized Signatu Add Date: Df~ 1)-3 Certificate of Immunization Supplement for 7th Grade Requirement PART A-2

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

ve with the 1997/98 school year: tetanus-diphtheria booster, hepatitis B vaccine series, and second dose of measles vaccine as docurn. Physician or Clinic Na Physician or (Print or stamp) horized Signatur Addr• Date: --1 1 St (C)--' . Temporary Medical Exemption PART B (For children in child care

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

e either physician documented or parental recall (fork' i year) for school attendance as documented on the reverse side of this form. Physician or Clinic Na Physician or (Print or stamp) Authorized Signatu Add Date: Df~ 1)-3 Certificate of Immunization Supplement for 7th Grade Requirement PART A-2