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(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

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I PHYSICIAN OR CONIC NAME (PLEASE PRINT) JATELY IMMUNIZED AGAINST 'DANCE. -//,1/2,73 DATE EFTA01710101 FLORIDA CERTIFICATION OF IMMUNIZATION Legal Authority: FLORIDA STATUTES 232.032, a 10D-3.088, F.A.C. and S. 10M-12, F.A.C. ATE PARENT OR GUARDIAN FIRS I MI DOB moinAnta Child's 5Stt (optional) ST

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