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Get and Sign California Elementary School Transfer Form 2001-2022
Name
Sex:
Name of Parent or Guardian
Race/Ethnicity:
M
F
Birthdate
Place of Birth
Address
White, not hispanic.
Hispanic
Telephone
Daytime
Nighttime
City
ZIP
Black
Other:
DATE EACH DOSE WAS GIVEN
I. DOCUMENTATION
VACCINE
1st
2nd
POLIO (OPV or IPV)
DTP/DTaP/DT/Td
MMR
HEPATITIS B
(Chickenpox)
Type*
Date given
Date read
Impression
mm indur
PPD-Mantoux
Other
Pos
Neg
PPD-Mantoux
Other
Pos
Neg
*If required for school entry, must be Mantoux unless exception granted by...
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