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IST YOLR DOW'S ILLNESSES. A.LERGiEs OR OTHER PHYSICAL LMITATIONS YOUR CHILDREN IN OTHER CHOOLS: :Ill NAME OF CHILD SCHOOL ATTENDING STUDENT NO. (OPTIONAL) GRADE OATH DATE tl 4IN — STUDENT NO. (OPTIONAL) GRADE 1531 NAME OF CHILD SCNOOI ATTENOING STUDENT NO. (OPTIONAL) GRADE BRIM DAVE 1641 NA
ve if additional space needed) C. LABORATORY (as indisated)., Hemoglobin /Hematocrit /cam • -6 NAM TITLE: ADORES (Please Print) Stool (0 & Tuberculin test: Sickle Cell ‘in Date 1ype -Fist date 7 / 34 1f results 9 OH 3040. 10196 (Riableces HRS44 Form 3040 which may ,(Stock Number. 5744-000-3
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
s I •• •r aM) (attach narrative if additional space needed) .:• C. LABORATORY (as indicated) • type Hernaglobin/Hematocrit Stool (O & PI Tuberculin lest " results dte Lead Sickle Cell NAME TITLE: ADDR (Pleas. NRS-N (Stock EFTA01709998 .ms 1%3 (344) OFFICE of VITAL STATISTICS CER
tit C--k--- , n . KM.' IA Ia' AAA( a, .., WEST PALM BEACH FL 33413 nt . Ltett 1... (SI STUCENTS SOCIAL SEE UM TT NO. 161 HOME PHONE NJ. (OPTIONAL) 0/ SLR F 0 „tome IlD R CE V 0 INDIANC" 0 A ASIAN psLANorq 9 W Zia rr-LISPANIC I MALI I g oNt....e_nmspaic 9 H HISPANIC 0 M I
Injur•es explain) (attach narrative if additional snipe needed) C. LABORATORY (as indicated) It. He-nOglobtrilklematocrit Stool 1O 8 P) d Tuberculin test. Lead Sickle tell r NAME: TITLE: ADDRESS: • (Please Print) A MRS -N Form 5040, Mar 91 (0bsotetes previous editions LIM Oat am
Entities connected to both OPTIONAL and Tuberculin

George W. Bush
PERSONLeon Black
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Palm Beach
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Ghislaine Maxwell
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PERSONCurriculum/ Information Meetings
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