AILABLE AND TO THE BEST OF MY KNOWLEDGE THE ABOVE NAMED CHI 9 HAS BEEN ADEQUATELY IMMUNIZED AGAINST DIPHTHERIA, TETANUS, PER RUBELLA AS REQUIRED BY Fl nnina I Ameono cflannl ATTENDANCE. PHYSICIAN OP CLINIC NAME (PLEASE PRINT) PHYSICIAN OR AUTHORIZE NATURE DATE EFTA01710124 Leac NAME: TITLE: ADD