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If you have questions on immunizations or how to complete this form contact your child s school or local health department. Step 2 PERSONAL DATA Student s Name PLEASE PRINT Birthdate Mo/Day/Yr Name of Parent/Guardian/Legal Custodian Step 1 Address Street City State Zip Gender School Grade School Year Telephone Number IMMUNIZATION HISTORY List the MONTH DAY AND YEAR your child received each of the following immunizations. DO NOT USE A OR X except to answer the question about chickenpox Tdap...
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