Epstein Secrets

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 - -

an asterisk fl the program your child was in the longest.) 0 Fee for Services 0 Head Start 0 Pre-K Disabilities 0 Private Pre-K 0 School-based (Pre-K) 0 Teenage Parent Program 0 None 3. Is the student who Is enrolling in school a single parent? 0 Yes 0 No N 4. Students will receive non-Invasive

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

th an asterisk lithe program your chid was in the longest.) O Fee for Services O Head Start O Pre-K Disabilities O Private Pre-K O School-based (Pre-K) O Teenage Parent Program O None 3. Is the student who is enrolling in school a single parent? O Yes O No N 4. Students will receive non-invasive

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 - -

an asterisk fl the program your child was in the longest.) 0 Fee for Services 0 Head Start 0 Pre-K Disabilities 0 Private Pre-K 0 School-based (Pre-K) 0 Teenage Parent Program 0 None 3. Is the student who Is enrolling in school a single parent? 0 Yes 0 No N 4. Students will receive non-Invasive