IMMUNIZATION STATUS CODE / VACCINATION CODE EFTA01710237 11 1 Students Full Name Addre Name of Parent or Guardian *Mkt t (Jr rIS11111.0% . DEPARTMENT OF HEALTH & REHABILITATIVE SERVICES EALTH EXAMINATIONS Date Phone Race LiifM r Sek—e— Birliadate A. HEALTH EXAMINATION Normal-N; Abnormal- A 1. Appearance N A 2. Ski/Nose