IMMUNIZATION ANNUAL REPORT OF COMPLIANCE FOR KINDERGARTEN AND SEVENTH GRADE COMPULSORY IMMUNIZATION - FLORIDA STATUTES 1003.22 Private School Information: Date Name of School: City County Zip Information on the person completing this form: Name: Position/Agency: Name of Principal: Phone Number: Student Information: List students not fully immunized. Indicate type of exemption or out of compliance.? A student whose exemption expires before the date on this form is out of compliance.? Name (Last, First) Grade Medical Exemptions Religious Exemption DH-681 30-Day Transfer Exemptions List Enrollment Date Out of Compliance Temporary DH-680 (Part B) List Expiration Date Permanent DH-680 (Part C)...
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