LAST NAME FIRST MI DOB (MO/DA/YR) Certificate of Immunization for K-12 Excluding 7th Grade Requirements PART A-1 (Immunizations are complete for school entry and attendance grades kindergarten through 12 with the exception of the 7th grade requirement) DOE Code 1 I have reviewed the records available, and to the best of my knowledge, the above named child has been adequately immunized against diphtheria, tetanus, patussis, polio, measles, mumps, rubella and hepatitis B (for kindergarten effective with the 1998/99 school year) for school attendance as documented on the reverie side of this form. Physician or Clinic Name: Physician or (Pant or stamp) Authorized Signature: Address: Date: Certificate of Immunization Supplement for 7th Grade Requirement PART A-2 (Immunizations are complete for students who enter or attend the 7th grade after the beginning of the 1997/98 school year. Each subsequent year thereafter, the next highest grade will be included in the requirement) DOE Code 8 I have reviewed the records available, and to the best of my knowledge, the above named child has received the following immunizations required for any and attendance in 7th grade effective with the 1997/98 school year: tetanus-diphtheria booster, hepatitis B vaccine series, and second dose of measles vaccine as documented on the reverse side of this form (boxed areal). Physician or Clink Name: Physician or (Print or'stamp) Authorized Signature: Add Royal Palm Date: rfrAl Temporary Medical Exemption PART B (For preschool children, children in day care and school children who are incomplete for immunizations in Part A-1 or A-2.) Invalid without expiration date. DOE Code 2 I certify that the above named child has received the immunizations documented on the reverse side of this form and has commenced a schedule to complete the required immunization. Additional immunizations are not medically indicated at this time. Physician or Clinic Name: (Print or sta