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TY MIAMI FL 33188.0001 NEW Charges Past Due Total Now Due AUG 21 2003 $228.20 EFTA01710059 • • I' FLORIDA CERTIFICATION OF IMMUNIZATION Legal Authority: sections 232.032, 402.305, 402.313, Florida Statutes; rules 640-3.011.65C-22.006, 65C-20.01I, Florida Administrative Code LAST NAME PARENT OR GUA

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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

th an asterisk lithe program your chid was in the longest.) O Fee for Services O Head Start O Pre-K Disabilities O Private Pre-K O School-based (Pre-K) O Teenage Parent Program O None 3. Is the student who is enrolling in school a single parent? O Yes O No N 4. Students will receive non-invasive

TY MIAMI FL 33188.0001 NEW Charges Past Due Total Now Due AUG 21 2003 $228.20 EFTA01727112 • • I' FLORIDA CERTIFICATION OF IMMUNIZATION Legal Authority: sections 232.032, 402.305, 402.313, Florida Statutes; rules 640-3.011.65C-22.006, 65C-20.01I, Florida Administrative Code LAST NAME PARENT OR GUA

an asterisk fl the program your child was in the longest.) 0 Fee for Services 0 Head Start 0 Pre-K Disabilities 0 Private Pre-K 0 School-based (Pre-K) 0 Teenage Parent Program 0 None 3. Is the student who Is enrolling in school a single parent? 0 Yes 0 No N 4. Students will receive non-Invasive