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Show UTAH CERTIFICATE OF IMMUNIZATION i 1 . . t,, t tilW in nd submitted to the school upon school entry. Parents' personal records may be acceded if thev TorniwmmUn," ,mmun,",'" information shouW then be transcribe toSSS by YOURCHILD MUST HAVE the following immunizations for school entry: , 4 Of more DTP snots 3 or more doses of polio vaccine , 1 mttsl" not 1 rubella shot . 1 mumDt 'lNm Birthdate ftrinti' Nm Telephone Addf City County-. -School rrHf IONIZATIONS: To t be completed by PHYSICIAN. SCHOOL or HEALTH AUTHORITY. Circle number of luniHtions completed (shaded numbers indictt minimum doses required). DATE of LAST unmunustion , DTPmdofTD ' 0 12 3 $4? 5 I OralPo'io 0 1 2 Slj: 4 5 3, Metsles 0 Slg 4, Rubella 0 fl 5, Mumps 0 gig , m reviewed the records Mailable and to the best of my knowledoe, this child has received the above circled jnmuniiitiont Signed . Date Phyucian. School QtntTaJ. HiUdi Authority - SEE BELOW - SIGN APPROPRIA TE STA TEUENT NOTE: THIS RECORD IS TO BE RETAINED WITH THE STUDENT'S PERMANENT SCHOOL RECORD. |