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

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

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

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

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

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