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

nical reasoning or evidence for exemption. DOE Code 3 1 cent that the physical condition of this child is such that immunization(s) as indicated in Pan C above is medically contraindicated. Physician or Clinic Name: (Print or stamp) Physician Signature: Address: DH 680, 8/2000, obsoktm tallitt

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

nical reasoning or evidence for exemption: DOE Code 3 I cent& that the physical condition of this child is such that immunizations) as indicated in Pan C above is medically contraindicated. Physician or Clinic Name: (Print or stamp) Physician Signature: Address: DII 450, Pd2000, obsoletes whet

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

inical reasoning or evidence for exemption: DOE Code 3 I cestift that the physical condition of this child Lt nth that immenitatiomNat indicated in Pan C above is medically caltraindicated. Physician or Clinic Name: (flint or stamp) Address: D44 610, 1196. dada= la (4Omo (SIM Maher 574.11O:MX1106)