Epstein Secrets

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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

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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

emediated ,,_. Requires New AIP Next Schott Year Special Senices 1 Placement Other (see attached) In Deficiencies due to non-attendance refer to Attendance Specialist) Number of Days Absent Parent/Guardian Contact CommItnentIContdbution O,ecl te 'het eppy. El Monitor Attendance I Tarries K Check Homework 0 Re