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Show REGISTRATION FORM hare read the above statement about .m ine flu. the vaedne. and the special precautions I have j I had an opportunity to a.k questions, including questions regarding vauinalion recommendations j I for persons under age 25, and understand lite benefits and rAv ofhi vaccination. I request lltat i I it he given to me or to the person named below of whom I am the parent or guardian. j I INFORMATION ON PERSON TO RECEIVE VACCINE FOR CLINIC USE ! rLmc tPlemt Print) " BirthcUW Age Dime Idtnl. I I Address County of Ketidcnco I D.iti VJCcmjted . J Mnuljcturcr and Lot No. j Sgnoturt! of person to teceive vaccine 01 Parent or Guardian D.itn I f |