Epstein Secrets

nical reasoning or evidence for exemption: DOE Code 3 I cent& that the physical condition of this child is such that immunizations) as indicated in Pan C above is medically contraindicated. Physician or Clinic Name: (Print or stamp) Physician Signature: Address: DII 450, Pd2000, obsoletes whet

name) (apt. no) (ulY) (stale) MP 0,(0!) BO SOCIAL SECURITY NO. Toptrone0 (9) HOME TELEPHONE NO. (10) F 1 (11)RACFJETHMC ORIGIN y • Native 0 B-Black, Non-Hispanic 0 H-Hispanic 0 W-White, Non-Hispanic 0 M-Multiracial I-American Indian/Alaskan • A-Asian/Pacific Islander (12) DATE OF MTH (leAUDD

inical reasoning or evidence for exemption: DOE Code 3 I cestift that the physical condition of this child Lt nth that immenitatiomNat indicated in Pan C above is medically caltraindicated. Physician or Clinic Name: (flint or stamp) Address: D44 610, 1196. dada= la (4Omo (SIM Maher 574.11O:MX1106)

RITY NO.PAPLOneg (I) HOME TELEPHONE NO. (10) S 1 F (I1) RACErETNNIC ORIGIN 0 I-American Indian/Alaskan 0 A-Asian/Pacific Islander W . Native 0 B-Black, Non-Hispanic 0 H-Hispanic 0 NI-Multiracial • W-VVhite, Non-HiSpanic (12) DATE OF BIRTH M TMARDCWYY (13t PLACE OF BIRTH (c4 stab. couphy) WEST

nical reasoning or evidence for exemption. DOE Code 3 1 cent that the physical condition of this child is such that immunization(s) as indicated in Pan C above is medically contraindicated. Physician or Clinic Name: (Print or stamp) Physician Signature: Address: DH 680, 8/2000, obsoktm tallitt

(ophone0 (9) HOME TELEPHONE NO. (12) DATE Of MTH (13) MACE OF BIRTH (city, LS ceneery) (11MAXWYYY) (1C) SE:1 F (11) RACE/Ell-RICORIGIN Native 0 B-Black, Non-Hispanic 0 W-White, Non-Hispanic • I-American Indian/Alaskan • H-Hispanic 0 A-Asian/Pacific Islander 0 M-Multiraclal (14) 0 RESIDENT STA