Epstein Secrets

SPITAL PROT:ROME 1501 LIST YOUR CHILD'S ILLNESSES, ALLERGIES OR OTHER PHYSICAL LIMITATIONS: aff 16I/ NAME OF CHILD SCHOOL ATTENDING STUDENT NO. (OPTIONAL) GRADE MATH OATE MI NAME OF CHILD SCHOOL ATTENDING STUDENT NO, (OPTIONAL) GRADE BIRTH DATE (53) NAME OF CHILD SCHOOL ArtFt.01M1Cr STUDENT N

ic (Print or Stamp) Add ACES, FLORIDA 33401 days after next Immunization appointment) Physician or Authorized Slgnat ed a schedule to I t o Permanent Medical Exemption PART C For medically contraindicated immunizations, list each vaccine and state valid clinical reasoning or evidence for exemption: DOE Code 3 cer

S, ALLERGIES OR OTHER PHYSICAL LIMITATIONS: A) 0 lie 0007,110- cg, p'Airiel eiTeci , 1511 NAME OF CHILD Aiorc • SCHOOL ATTENDING STUDENT NO. (OPTIONAL) GRADE RIM DATE 1521 NAME Of CHILD SCHOOL ATTENDING STUDENT NO, (OPTIONAL) GRACIE BIRTH DATE (531 NAVE OF CHILD SCHOOL ATTENDING STUDENT NO

• (Print or Stamp) Address: Expirati0n Date' _Olitlazufttstualimaadzatisin atipSathunD *LI Physician or Authorized Signature. Date. Permanent Medical Exemption PART C For medically contraindicated immunizations, list each vaccine and state valid clinical reasoning or evidence for exemption: DOE Code 3 I c

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. Physician or Clinic Name: (Print or stamp) Address: xpirAtion ate osaasiltroexibmigilitkitiir Physician or Authorized Signature: Date: Permanent Medical Exemption PART C For medically contraindicated immunizations, list each vaccine and state valid clinical reasoning or evidence for exemption: DOE Code 3 I c

GRACE BIRTH DATE 154) NAME OF GILD SCHOOL ATTENDING STUCENT NO (OPTIONAL) GRACE BIRTH DATE (55) NAME OF CHID SCHOOL AT HEADING STUCENT NO. (OPTIONAL) GRACE SIREN DATE ISO) I VERIFY THAT THE INFORMATION GIVEN IS TRUE AND ACCURATE TO THE BEST CF MT KNOWLEDGE. SIGNATURE OF PARENT OR AGE( GjAROIA

an or Clinic Name: (Print or stamp) Address: Expiration Date: (r9 dart after nest humanization appo Physician or Authorized Signature: Date: Permanent Medical Exemption PART C For medically contraindicated immunizations, list each vaccine and state valid clinical reasoning or evidence for exemption: DOE Code 3 I c

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rvice Address: Riviera Bea L 33404 Phone: Expiration Date: (IS days after next Physician or Authorized Signatu A. 41/21-4goo/ w 7 3.0) •, Permanent Medical Exemption PART C For medically contraindicated immunizations, list each vaccine and state valid clinical reasoning or evidence for exemption: DOE Code 3 / c