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

SCHOOL TRANSFERRING FROM (20) CITY /STATE icouNre COUNTRY (21) LAST ATTENDANCE DATE (22) LAST GRADE LEVEL (23) Have you ever been enrolled In a Palm Beach County School? 0 YES 0 NO If yes, what school? _ 200 DATE ATTENDED IN PBC All new and returning students compete the remaining form including page 2 (2s) Stud

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

CHOOL TRANSFERRING FROM (2[9 CITY! STATE /COUNTY COUNTRY . (21) LAST ATTENDANCE DATE (72) LAST GRACE LEVEL (23) Have you ever been enrolled in a Palm Beach County School? If yes, what school? • YES 0 NO (24)DATE ATTENDED 94 PSC All new and returning students compete the remaining form including page 2 p2si Studen

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

adiness Program O Z. Not OS) Is the student a single parent? O YES O NO TRANSFER INFORMATION ("Para; 13e4ch Ft- (23) ave you ever een enrolled In Palm Beach County School? W YES O NO If yes, what school? (21) LAST ATTENDANCE DATE a - L4 - (21) DATE ATTENDED IN Pac HEALTH SCREENING INFORMATION (25 ) Students will

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

E Cf SCHOOL TRANSFERRING FROM (20) WWI STATE I COUNTY =WRY (21) LAST ATTENDANCE DATE (22) LAST GRADE LEVEL (23) Have you ever been enrolled In a Palm Beach County School? DYES 0 NO If yes, what school? (21) DATE ATTENDED IN PBC All new and returning students compete the remaining form including page 2 rzsi Student