Epstein Secrets

ne only) te Both Parents 0 Mother 0 Father 0 Foster 0 Group Home 0 Student is ward of the state Ot

been arrested resulting in a charge. of applicable 10. AInd with whom the student lives (check one only) te Both Parents 0 Mother 0 Father 0 Foster 0 Group Home 0 Student is ward of the state Other 11. IMPORTANT, EVERYONE MUST ANSWER THIS QUESTION. A. Is there a visitation order or other court

I PHYSICIAN OR CONIC NAME (PLEASE PRINT) JATELY IMMUNIZED AGAINST 'DANCE. -//,1/2,73 DATE EFTA01710101 FLORIDA CERTIFICATION OF IMMUNIZATION Legal Authority: FLORIDA STATUTES 232.032, a 10D-3.088, F.A.C. and S. 10M-12, F.A.C. ATE PARENT OR GUARDIAN FIRS I MI DOB moinAnta Child's 5Stt (optional) ST

(check one) 0 Mother 0 Father 0 Both Parents 0 Foster 0 Group Home (31) CUSTODY STATUS OF STUDENT (aec

14 Form 3040 which easy be used) Mock Plumbot. 5744400.3040-2) Authorized Signature-- Date EFTA01709711 FLORIDA CERTIFICATION OF IMMUNIZATION Legal Authority: sections 232.032, 402.305, 402.313, Florida Statutes; rules 64D-3.011, 65C-22.006, 65C-20.011, Florida Administrative Code LAST NAME PARENT OR GU

WITH: (chock ro D Mother 0 Father oth Parents 0 Foster 0 Group Home 0 Other ' (31) CUSTODY STATUS OF

WL MRS- /I ion 3040, Mar 9 (Stock Weber: 5744.000.3040-2) Mod JO SPI *Ostlers) ---4110ato EFTA01709961 FLORIDA CERTIFICATION OF IMMUNIZATION Legal Authority: FLORIDA STATUTES 23L037., a. 20D4.088, F.A.C. and s. 10M-12, P.A.C. LAST NAME PARENT OR GUARDIAN FIRST MI DOB MOIDNYR Child's SS* (optional)

ck one only) Both Parents 0 Mother 0 Father 0 Foster 0 Group Home 0 Student is ward of the state O

TY MIAMI FL 33188.0001 NEW Charges Past Due Total Now Due AUG 21 2003 $228.20 EFTA01710059 • • I' FLORIDA CERTIFICATION OF IMMUNIZATION Legal Authority: sections 232.032, 402.305, 402.313, Florida Statutes; rules 640-3.011.65C-22.006, 65C-20.01I, Florida Administrative Code LAST NAME PARENT OR GUA

(check one) 0 Mother 0 Father 0 Both Parents 0 Foster 0 Group Home 0 Other (31) CUSTODY STATUS OF STU

(46f DATA ENTRY COMPLETED BY DATE S/ DATE PBSD 0636 (REV. 4/6/20015.29/2001) page 2 of 2 EFTA01710389 FLORIDA CERTIFICATION OF IMMUNIZATION Legal Authority: FLORIDA STATUTES 232.032, s. 10D-3.088, F.A.C. and s. 10M-12, F.A.C. LAST NAME PARENT OR GUARDIAN Directions: • Enter all appropriate doses and

ck one only) Both Parents 0 Mother 0 Father 0 Foster 0 Group Home 0 Student is ward of the state O

TY MIAMI FL 33188.0001 NEW Charges Past Due Total Now Due AUG 21 2003 $228.20 EFTA01727112 • • I' FLORIDA CERTIFICATION OF IMMUNIZATION Legal Authority: sections 232.032, 402.305, 402.313, Florida Statutes; rules 640-3.011.65C-22.006, 65C-20.01I, Florida Administrative Code LAST NAME PARENT OR GUA