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Ill out the information requested in Section I. Section III may be certified by the transcription of information from the certificate of immunization. The remaining sections are to be completed by a doctor, nurse and dentist. (BE SURE TO BRING YOUR CHILD S IMMUNIZATION RECORDS TO THE EXAMINATION.) PERSONAL CHILD S NAME (Last, First, Middle) DATE OF BIRTH (mm/dd/yy) ADDRESS (Number & Street) (City).
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