Epstein Secrets

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

student resides on federal property. 2 /6 " • The student resides In low rent housing. 0 ' The parent is employed on federal property located in P.B. County. 0 The parent is employed on low rent housing located in P.B. County. 0 E. The parent Is In the uniformed services of the United States. 0 0 If E

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

udent resides on federal property. • 0 B. The student resides in low rent housing. O Iii C. The parent is employed on federal property located in P.B. County. C e D. The parent is employed on low rent housing Vacated In P.B. County. C71 E The parent is in the uniformed services of the United States. O 0

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 student resides on federal property 0 0 B. The student resides n low rent housing U U C. The parent is employed on federal property located in P.B. County 0 3 D. The parent is employed on low rent housing located n P B. County 0 o E. The parent is in the uniformed services of the Unted States ic) NIC