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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
0 The student most frequently speaks a language other than English. What language/ What language? What language/ (29) DISCLOSURES FOR ENTRY INTO PSC SCHOOL DISTRICT (Check ON the! apply) had juvenile justice aerials taken against himiher. 0 The student has been expelled from school. • The student has III The
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
date of entry into an ESOL program? (32) STUDENT LIVESMATH. (chock coat %pother li Father xi Both Parents 0 Other (33) Oscuosunas FOR ENTRY 0/10 PSC SCHOOL DISTRICT YES NO CI rag Pi been 1. Has the student ever expelled from school? • . 4 2. Has the student ever had an arrest resulting in a charge? 0 !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
0 The student most frequently speaks a language other than English. What language? What language? What language? (2a) OSCLOSURES FOR ENTRY INTO PSC SCHOOL DISTRICT (cheek ell Mel epohi) had juvenile justice actions taken against himtner. • The student has been expelled from school. 0 The student has • The st
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