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tende bang index« enen. nemmes, and pas's. to Wild rrtcnnation for a vanety of aromen sYntheerand a
earles vaccine as documented on the reverse side of this fonn (bared Physician or Clinic Name: (Print or stamp) Address: THE PEDIATRIC CENTER, P WELLINGTON, FLORIDA 33414 Physidan or Signature: Date: a Ss Temporary Medical Exemption PART B (For preschool children, children in day care and school ch
mes and I like to be with time partying, gettin wild and havin the beach, surf, and wove run and any
1800 C 1839 OCCURRED BETWEEN DATE: 04/23/05 , 1800 HOURS AND DATE: 05/04/05 , 1500 HOURS EXCEPTION TYPE: INCIDENT LOCATION: ED APT. NO.: CITY: WELLINGTON STATE: FL ZIP: 33414 NO. OFFENSES: 00 NO. OFFENDERS: 00 NO. VEH. STOLEN: 0 NO. PREM, ENTERED: 0 LOCATION: OTHER NO. VICTIMS: 00 NO. ARRESTED: 0
N FL ELECTRONICS STORE 384.79 04/09m BUFFALO WILD WINGS BATLANTA GA 404.763.4779 $19.03 04/0g/i
954-491-0094 08870007 33309 General Tobacco General Merchandise 5878 03/29/15 GOGOAIR.COM 877-350.0038 IL INTERNET ACC $1885 03/29/IS PDQ WELLINGTON WELLINGTON www.eatpdq.com FL 52137 03/29/15 BANYAN AIR SERVICE 01954)491.3170 PETROLEUM PRODUCTS FL $180.20 AMEX004036 Continued on revers
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