OCR Text |
Show THIS SIDE OF CARD MUST BE COMPLETED FOR SCHOOL ENTRY SIGN STATEMENT BELOW WHICH APPLIES r A. This child is adequately immunized. Signed Date Nun or School Personnel B. My child i$ not adequately immunized. I will provide satisfactory evidence to the school that hisher ' immunizations will be completed. -i: Signed , Date V Parent or Guardian C. The physical condition of this child is such that immunization would endanger the child's health. a Contraindication(s) Signed Date Physician D. I certify that immunization is contrary to my religious beliefs. I refuse to permit my child to be immunized. im-munized. Signed , Date Parent or Guardian I 5 E. I certify that immunization is contrary to my personal beliefs. I refuse to permit my child to be im-j im-j munized. I Signed Date j Parent or Guardian 1 1 . 1 |