Epstein Secrets

K Early Intervention 0 C. Chapter 1 0 S. Subsidized Child Care 0 O. Other 0 0 If E. is YES, is the parent on active duty? Check service below: 0 Air Force 0 Anny 0 Coast Guard 0 Marines 0 National Guard 0 Navy (IntS DC STUDENT A SINGLE P 0 YES NO ( 8) CURRENT GRADE LEVEL . ey dfrc, • • / I9 NA

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

rent is in the uniformed services of the United States. 0 Yes a No If "E" Is YES, Is the parent on active duty? 0 Yes 0 No (check service below) 0 Air Force 0 Army 0 Coast Guard 0 National Guard 0 Navy 0 Marines 2. Preschool Enrollment Information (Check each program attended. Indicate with an aste

Clinic Name: Expiration Date: (Print or sump) (15 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 - -

K Early Intervention 0 C. Chapter 1 0 S. Subsidized Child Care 0 O. Other 0 0 If E. is YES, is the parent on active duty? Check service below: 0 Air Force • Army 0 Coast Guard 0 Marines 0 National Guard 0 Navy (17) ISIHE STUDENT A SNORE PARENT? NO 0 YES 0 NO Om CURRENT GRADE LEVEL 07 4TRANSEEWI

ic Name: 05•days after next immuilization.appoiutrnent) (Print or stamp) . . _ . . . • 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

rent is in the uniformed services of the United States. 0 Yes a No If "E" Is YES, Is the parent on active duty? 0 Yes 0 No (check service below) 0 Air Force 0 Army 0 Coast Guard 0 National Guard 0 Navy 0 Marines 2. Preschool Enrollment Information (Check each program attended. Indicate with an aste

Clinic Name: Expiration Date: (Print or sump) (15 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 - -