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sician or Clinic Name: (Print or stamp) Address: Expiration Date: (15 days after ant inuntuthafteei appointment) hvsician or ignature: Date: Permanent Medical Exemption PART C For medically contraindicated immun exemption: DOE Code 3 tions, list each vaccine and state valid clinical reasoning or evidence for I ce
ly crossing out the incorrect information and writing the correct information above I V ) Wei trio code) o/yei L Alai /J4'// el ,,,yi, !rm....GM:MRCSS (noose mammy/ name, Oa no) (0,4 (axe) ('I code) (I) SOCIAL SECURITY NO. (a) HOME TELEPHONE NO (9) SEX (10)RACEJETHNICOR.GIN (44444.49 01
nic Name: (Print or stamp) Expiration Date: (t5 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 I c
Grade Tested 10 Achievement Level NT FCAT Score • NT FCAT Score 3000 Reading 2500- 2000- 1500- 1000- S00- Grade 9 Grade et Grade Grade I GM* Gracie a Grade Grad 10' 11+ • Your Score O On Grade Level You did not score well enough to pass the Grade 10 FCAT Mathematics lest. Your Math
ic (Print or Stamp) Add ACES, FLORIDA 33401 days after next Immunization appointment) Physician or Authorized Slgnat ed a schedule to I t o Permanent Medical Exemption PART C For medically contraindicated immunizations, list each vaccine and state valid clinical reasoning or evidence for exemption: DOE Code 3 cer
SHOULD SE AWARE OF, PLEASE LIST YOUR:.CIELDAENANIOINER latitEACH4gOUNTMSCHOOILSWSVSEKS•M-r: Sig,(4.:?ofp:n:w, ',/4M<Iti .;:fgft.tMita•c)fl . we4 (GM MAYEISI OF OAD0CNI (CS) SCHOOL ATTENDING (7C) STUDENT NO. (OPTIONAL) (711 GRADE O21 BIRTH DATE EFTA01710376 4 .14 - OOL Di's, \ 41 VERIFICATI
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
u earned for your answer is shown in the box to the right. Ike Nam diva Is owed Magian' plats that awned Wend with ea el Gahm ;Nor Ter tonte plebs GM* Wald Dewar a poker erect ant a mole& fortnatIon that cm row when plate cralide. \4r ern WAes rt.n ram ink a (Tv: e;;Olono . at NM ).4 a die FC
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
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