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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

ns taken against him/her. 0 The student has arrested resulting in a charge. (30) STUDENT LIVES WITH: (check one) 0 Mother 0 Father 0 Both Parents 0 Foster 0 Group Home (31) CUSTODY STATUS OF STUDENT (aeck tee) 0 Mother 0 Father 0 Shared Custody E Other • Other CRS: SEC:OO1 BLDG:O3 RM:212 O6 11 O4 IMPORTANT

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)

actions taken against him/her. DI The student has wrested resulting in a charge. (30) STUDENT LIVES WITH: (chock ro D Mother 0 Father oth Parents 0 Foster 0 Group Home 0 Other ' (31) CUSTODY STATUS OF S7111:Off (check one) 0 Mother K Father 0 Shared Custody 0 Other IMPORTANT INFORMATION - MUST BE COMPLETED t

(46f DATA ENTRY COMPLETED BY DATE S/ DATE PBSD 0636 (REV. 4/6/20015.29/2001) page 2 of 2 EFTA01710389 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 Directions: • Enter all appropriate doses and

hool. • The student has III The student has arrested resulting In a charge. (30) STUDENT LIVES WITH (check one) 0 Mother 0 Father 0 Both Parents 0 Foster 0 Group Home 0 Other (31) CUSTODY STATUS OF STUDENT (check one) 0 Mother 0 Father 0 Shared Custody 0 Other NBR:O23 STDT: CRS:21O46OO SEC:OO4 BLDG:O2 RM:2