Epstein Secrets

ALTH HISTORY (Serious Illnesses Inures explain) (attach narrative it additonal space needed) C. I ARARATARY Ina inelinlaelli e Tuberculin test Sickle Cell type date result NAME: TITLE: ADDRESS: (Please Print) r-rdl- OH 3040. 10116 (lieplooli 14R5-14 Form 3040 which easy be used) Mock Plumbot. 5

SCHOOL TRANSFERRING FROM (20) CITY /STATE icouNre COUNTRY (21) LAST ATTENDANCE DATE (22) LAST GRADE LEVEL (23) Have you ever been enrolled In a Palm Beach County School? 0 YES 0 NO If yes, what school? _ 200 DATE ATTENDED IN PBC All new and returning students compete the remaining form including page 2 (2s) Stud

n) (attach narrative d additional space needed) C. LABORATORY (as indicated) t- rnoglcbin/Hemafocrit Stool (O & Tuberculin test: LP 1C1 Sickle Cell d NAME: TITLE: ADDRESS: (Please Print) 1 7A /7 5 OH 3040. 10/16 (Rapacas HRS-ef Form 3040 when may 0* oseie) (Stock Nwnbsr 57444430 JU0 2)

CHOOL TRANSFERRING FROM (2[9 CITY! STATE /COUNTY COUNTRY . (21) LAST ATTENDANCE DATE (72) LAST GRACE LEVEL (23) Have you ever been enrolled in a Palm Beach County School? If yes, what school? • YES 0 NO (24)DATE ATTENDED 94 PSC All new and returning students compete the remaining form including page 2 p2si Studen

Illnesses Injuries: explain) (attach narrative it additional space needed) C. LABORATORY Hemoglobin/Hematocrit Stool 1O & P) Tuberculin test: Sickle Cell Lead Authorized Signature OH 3040. 10190 (Replaces NRS-li Form 3040 which may be used) (Slack Number 5741-000-3040-2) EFTA01710221 ERs Studen

adiness Program O Z. Not OS) Is the student a single parent? O YES O NO TRANSFER INFORMATION ("Para; 13e4ch Ft- (23) ave you ever een enrolled In Palm Beach County School? W YES O NO If yes, what school? (21) LAST ATTENDANCE DATE a - L4 - (21) DATE ATTENDED IN Pac HEALTH SCREENING INFORMATION (25 ) Students will