1. ? ________________________________________ 4. Kindergarten ______ Seventh Grade ________ 8. _________________________________ Name of School ( Please check only one grade) Date 2. ? ________________________________________ 5. ________________________________________ 9. _________________________________ Address Person Completing Report Total Enrollment ________________________________________ 6. ________________________________________ 10. Total Fully Immunized ____________ City County Zip Position/... 3. ? ________________________________________ 7. ________________________________________ Name of Principal Phone Number of Person Completing Report 11. List Students with Medical and ...
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