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Get IL CFS 600 2013-2024

Ce/Ethnicity School /Grade Level/ID# Month/Day/Year Zip Code Parent/Guardian Telephone # Home Work IMMUNIZATIONS: To be completed by health care provider. Note the mo/da/yr for every dose administered. The day and month is required if you cannot determine if the vaccine was given after the minimum interval or age. If a specific vaccine is medically contraindicated, a separate written statement must be attached explaining the medical reason for the contraindication. 1 MO DA YR 2 MO DA YR .

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