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 - -

nt have any allergies? (if yes specify) f'Yes 0 No Allergy 1 18. Physician Name 1 J c•12,n APIA. 01/4.A Telephone Number Parental Consent for Release of Student Information I hereby give permission for the school or District to use my chikfs photograph, video Image, writing, voice recording, name, grade level, school n

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

dents illnesses, behavior issues, medications or physical limitations. student will use. 18. Physician Name Telephone Number Parental Consent for Release of Student Information I hereby give permission for the school or District to use my chid's photograph, video image, varkig, voice recording, name, grade level, school na

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 - -

student have any allergies? (if yes specify) 'Yes CI No Allergy 1 18. Physician Name 1 J ce-4., inn tc,k Telephone Number Parental Consent for Release of Student Information I hereby give permission for the school or District to use my chikfs photograph, video Image, writing, voice recording, name, grade level, school n