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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)

e student resides on federal property. O O B. The student resides in low rent housing. O O C. The parent is employed on federal property located In P.B. County. O O D. The parent is employed on low rent housing located In P.B. County. O O E. The parent Is in the uniformed services of the United States. O

(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

student resides on federal property. 2 /6 " • The student resides In low rent housing. 0 ' The parent is employed on federal property located in P.B. County. 0 The parent is employed on low rent housing located in P.B. County. 0 E. The parent Is In the uniformed services of the United States. 0 0 If E

FLORIDA CERTIFICATION OF IMMUNIZATION Legal Authority: sections 232.03Z, 402.305, 402.313, Florida Statutes; rules 640-3.011, 65C-22.006, 65C-20.011, Florida Administrative Code LAST N FIRST NAME MI

udent resides on federal property. • 0 B. The student resides in low rent housing. O Iii C. The parent is employed on federal property located in P.B. County. C e D. The parent is employed on low rent housing Vacated In P.B. County. C71 E The parent is in the uniformed services of the United States. O 0

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

e student resides on federal property 0 0 B. The student resides n low rent housing U U C. The parent is employed on federal property located in P.B. County 0 3 D. The parent is employed on low rent housing located n P B. County 0 o E. The parent is in the uniformed services of the Unted States ic) NIC