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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

nt have any allergies? (if yes specify) f'Yes 0 No Allergy 1 18. Physician Name 1 J c•12,n APIA. 01/4.A Telephone Number Parental Consent for Release of Student Information I hereby give permission for the school or District to use my chikfs photograph, video Image, writing, voice recording, name, grade level, school n

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

dents illnesses, behavior issues, medications or physical limitations. student will use. 18. Physician Name Telephone Number Parental Consent for Release of Student Information I hereby give permission for the school or District to use my chid's photograph, video image, varkig, voice recording, name, grade level, school na

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

student have any allergies? (if yes specify) 'Yes CI No Allergy 1 18. Physician Name 1 J ce-4., inn tc,k Telephone Number Parental Consent for Release of Student Information I hereby give permission for the school or District to use my chikfs photograph, video Image, writing, voice recording, name, grade level, school n