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Get HPV Vaccine Refusal Form - District Of Columbia Public Schools

On 2: Have parent/guardian or student (if 18 years of age or older) sign and date after reading the HPV Information Statement. Section 1: Student Information Name of School: Student Name: Date of Birth: Grade: Street Address: City/State: Zip Code: Phone: Name and Address of Healthcare Provider: City/State: Zip Code: Phone: Beginning in 2009 and in accordance with D.C.Law17-10 (Human Papillomavirus Vaccination and Reporting Act of 2007), the parent or legal guardian of a female student.

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