LEDGE THE ABOVE NAMED CHILD HAS BE Rip TETANUS, PERTUSSIS, POLIO, MEASLES, MUMPS, AND RUBELLA AS REQUIRE PHYSICIAN CR CLINIC NAME (Fl FASF PRINT) ?cE"AUTOMATED STUDENT DATA BASE CODES IMMUNIZATION STATUS CODE / VACCINATION CODE EFTA01710237 11 1 Students Full Name Addre Name of Parent or Guardian *Mkt t (Jr rIS