Epstein Secrets

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

services of the United States. 0 0 If E. Is YES, is the parent on active duty? Check service below: 0 Air Force 0 Army 0 Coast Guard 0 Marines 0 National Guard 0 Navy indicate wilh an he longest. Prekindergarten Prekindergarten Parent Program Applicable (17) PRESCHOOL ENROLLMENT IsFORIAATION Place an X by e

an or Clinic Name: (Print or stamp) Address: Expiration Date: (r9 dart after nest humanization appo Physician or 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

ed services of the United States. 0 0 If E. Is YES, Is the parent on active duty? Check service below: 0 Air Force 0 Army • Coast Guard 0 Marines 0 National Guard 0 Navy (10 PRESCHOOL ENROLLMENT INFORMATION Place an X by each program attended. Also, indicate with an asterisk r ) the program your child was In the lon

ic Name: 05•days after next immuilization.appoiutrnent) (Print or stamp) . . _ . . . • 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

sidized Child Care 0 O. Other 0 0 If E. is YES, is the parent on active duty? Check service below: 0 Air Force • Army 0 Coast Guard 0 Marines 0 National Guard 0 Navy (17) ISIHE STUDENT A SNORE PARENT? NO 0 YES 0 NO Om CURRENT GRADE LEVEL 07 4TRANSEEWINEORMATION ;a6„...-Waiftt 09) NAME OF SCHOOL TRANSFERFtr

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

. Subsidized Chid Care 0 0. Other 0 0 If E. is YES, s the parent on active duty? Check service below' 8 Air Force D Army Coast Guard 0 Marines 0 National Guard 0 Navy 17) iS THE STUDENT A SI LE PARENT, NO 0 YES 0 NO (IL) CURRENT CRAM LEVEL 08 TRANSFER INFORMATION (zo)C01. OR LOCATION (211 LAST ATTE/OO.CE 0A