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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)
K Sixassluly Rernadaled O Regales Non' MP Nor SOS Year 0 Snail Sera I Pecirent O Otte (see eftscheci) O Deficiencies die to nonattendance OW to Attendance Specialist) Paant/Guardlan COMMItmenUCoritribUtiOn Ova as That •0•Y O Monitor Attendance I Tank** K Chock Homework O Encourage Rimdm3 at Home Reinforce Sk
••• --._.. .P.tyar•.b= fietv: EFTA01709855 EFTA01709856 FLORIDA CERTIFICATION OF IMMUNIZATION Legal Authority: sections 232.032, 402305, 402.313, Florida Statutes; s 64D-3.011, 65C-22.006, 65C-20.011, Florida Administrative Code Fl T NAME MI CHILD'S SS#
l Services I Placement • Special Services! Placement • Other (see attached) O Other (see attached) K Deficiencies due to non-attendance (refer to Attendance Specialist) Number of Days Absent Parent/Guardlan Contact Commitment/Contribution Checkoff Mal apply. O Monitor Attendance / Tardies O Check Homework O Re
be between 1750 and 1856. NT-Not Tested NR-Not Reported Data Run Date: 11/22/2004 0115263 EFTA01710024 FLORIDA CERTIFICATION OF IMMUNIZATION Legal Authority: FLORIDA STATUTES 232.032,8.64D-3.011, F.A.0 ands. 65C-22.00C F.A.C. FIRST Child'sSW (optional) MIAR IM DO MO/DA/YR STATEIMMUNIZATION ID#' Dire
2EACH RET: COM GR: 10 0: 18 MATH: 43 READ: 276 MATH: 285 LEP: AIP: R-FZ W-ZZ M-FZ S-ZZ 504: O Deficiencies due to non-attendance (refer to Attendance Specialist) Number of Days Absent PartuittGuardlan Contact Commitment/ContrIbution Check./ thatapply. O Monitor Attendance I Tardies O Check Homework O Re
(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
ment 0 Other (see enacted) 0 Other (see attached) 0 Other (see attached) K Other (see attached) [1] Deficiencies due to non-attendance (refer to Attendance Specialist) Number of Days Absent ParentlGuardlan Contact Commitment/Contribution Check as that appiy D Monitor Attendance / 'rarefies EI Read with Child E
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
emediated ,,_. Requires New AIP Next Schott Year Special Senices 1 Placement Other (see attached) In Deficiencies due to non-attendance refer to Attendance Specialist) Number of Days Absent Parent/Guardian Contact CommItnentIContdbution O,ecl te 'het eppy. El Monitor Attendance I Tarries K Check Homework 0 Re
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