BOANR) DATED/DMA/YR! DATE IIADAIVER) DATE IMONTATERT DATE (M0f0A/VR) OTP A OT 8 IC C POLO D HO E WAR F ANGELA (MEASLES) G IMAM MI (MOBAJYR) MOWS H ISICIAD BE *DAYS WIER NEXT APPENDANT) RUBELLA I EWSIDIAN OR AUTHORIZED SIGNATURE DATE PERMANENT MEDICAL EXEMPTION (HRS 680 - PART CI