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 - -

Lake Central Elementary School Academic Record — Name Birth Cm Birth / / BANb sz"LlnYoli5r947r7"-='-' COMPUTER FRENCH HEALTH HOME EC. LANG ARTS LIT MATH SCIENCE SOCIAL STUDIES A 0.250 : TOTALW 0.250: • 7.000 D.250 • Rank in Class of 0.250 88 / 300 1.000 ' Absence Tardies • 1.0

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

81 CURRENT SCHOOL: IMODUREVIT GRADE: 03 SCHL TRH COURSE TITLE SP EP ROOM 1 2 3 4 FGECAB SCHL TRH COURSE TITLE SP BP ROAN 1 2 3 4 FGEC AB 5101 A LANG ARTS 0051 5101 A READING 0051 5101 A MATHMATIC 0051 5101 A SCIENCE 0051 5101 A SOC STUDY 0051 5101 A ART 51 5101 A MUSIC 51 5101 A PHIS ED

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 - -

Lake Central Elementary School Academic Record — Name Birth Cm Birth / / BANb sz"LlnYoli5r947r7"-='-' COMPUTER FRENCH HEALTH HOME EC. LANG ARTS LIT MATH SCIENCE SOCIAL STUDIES A 0.250 : TOTALW 0.250: • 7.000 D.250 • Rank in Class of 0.250 88 / 300 1.000 ' Absence Tardies • 1.0