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nic Name: (Print or stamp) Expiration Date: (t5 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 I c

CHOOL ATTENDED IN PALM BEACH COUNTY (T4) CATE Al TENDED IN PDC, C E Etti!„ (25) Students will receive non-invasive health screenings pursuant to Florida Statute § 381.0056(7)(d). Non-invasive • screenings may include vision, hearing, scoliosis, height, and weight. These tests may be given individually or in groups. Parents

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 - -

None 3. Is the student who Is enrolling in school a single parent? 0 Yes 0 No N 4. Students will receive non-Invasive health screenings pursuant to Florida Statute § 381.0056(7)(d). Non-invasive screenings may include vision, hearing, scoliosis, height, and weight. These tests may be given individually or in groups. Parents or

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 - -

None 3. Is the student who Is enrolling in school a single parent? 0 Yes 0 No N 4. Students will receive non-Invasive health screenings pursuant to Florida Statute § 381.0056(7)(d). Non-invasive screenings may include vision, hearing, scoliosis, height, and weight. These tests may be given individually or in groups. Parents or