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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)
e date of entry Into an ESOL program? 0 032) silken LNES WITH (check one) Mother 0 Father 0 Both Parents 0 Other (33) DISCLOSURES FOR ENTRY INTO PBC SCHOOL DISTRICT YES NO 0 0 I. Has the student ever been e,pelled from school? 0 0 2. Has the student ever had an arrest resulting in a charge? 0 0 3. Has th
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
an ESOL program? (32) STTENT IJVES WITH: kited cone) V2 Mother O Father O Both Parents VOtper ‘ 214t sbPstiCEWKS (33) DISCLOSURES FOR ENTRY INTO PBC SCHOOL DISTRICT YES 14)," O 4 . _A. Has the student ever been expelled from school? O ril i 2. Has the student ever had an arrest resulting in a charge? O NY
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)
he date of entry Into an ESOL program? (32) STUDENT LIVES %1111. &Saone) O Mother O Father O Both Parents O Other (33) DISCLOSURES FOR ENTRY INTO PBC SCHOOL DISTRICT YES NO O • 1. Has the student ever been expelled from school? O O 2. Has the student ever had an arrest resulting in a charge? O O 3. Has the
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