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

0 The student most frequently speaks a language other than English. What language/ What language? What language/ (29) DISCLOSURES FOR ENTRY INTO PSC SCHOOL DISTRICT (Check ON the! apply) had juvenile justice aerials taken against himiher. 0 The student has been expelled from school. • The student has III The

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

date of entry into an ESOL program? (32) STUDENT LIVESMATH. (chock coat %pother li Father xi Both Parents 0 Other (33) Oscuosunas FOR ENTRY 0/10 PSC SCHOOL DISTRICT YES NO CI rag Pi been 1. Has the student ever expelled from school? • . 4 2. Has the student ever had an arrest resulting in a charge? 0 !e

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

0 The student most frequently speaks a language other than English. What language? What language? What language? (2a) OSCLOSURES FOR ENTRY INTO PSC SCHOOL DISTRICT (cheek ell Mel epohi) had juvenile justice actions taken against himtner. • The student has been expelled from school. 0 The student has • The st