Epstein Secrets

if checked provide a copy) PBSD 0636 (Rev. 01/26/2005) page 1 of 2 EFTA01710040 STUDENT LEGAL NAME MN Rat middle) 9. Disclosures for entry into Palm Beach County School District (check all that apply) O The student has had Juvenile Justice actions taken against him/her. 0 The student has been expelled from School O The stud

Clinic Name: Expiration Date: (Print or sump) (15 days after next immunization appointment) Physician or Address: 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 - -

r Plan? (I Medi& provides copy) P650 0636 (Rev. oit2smos) pap 1 of 2 EFTA01710075 LEGAL NAME pea( 6* t .,, fS " b. Disclosures for entry into Palm Beach County School District (check all that apply) 0 The student has had juvenile justice actions taken against him/her. 011ie student has been expelled from school. 0 The s

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

if checked provide a copy) PBSD 0636 (Rev. 01/26/2005) page 1 of 2 EFTA01727093 STUDENT LEGAL NAME MN Rat middle) 9. Disclosures for entry into Palm Beach County School District (check all that apply) O The student has had Juvenile Justice actions taken against him/her. 0 The student has been expelled from school O The stud

Clinic Name: Expiration Date: (Print or sump) (15 days after next immunization appointment) Physician or Address: 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 - -