Page | of 1 == (alseR PERMANENTE. jane : BOUCHARD: |zerent Guardian ‘COLORADO DEPARTMENT OF=PUBLIC HEALTH AND ENVIROMGNT-CERTIFICATE OF TMGNIZATION TOLER, BEN ——=— Date of Birth : 01/20/1998 ‘COLORADO DEPARTMENT OS=SUBLIC HEALTH AND ENVIRONMENT-CERTIFICATE OF TVAONIZATION Vasine =I ‘acorns rir concede each Runiztion was ven wisp sae — wear [reno | ooTeoe OTaP Tipe Te eens pam) | eons [-osztane | orzaane | oaranmee | oaTerane oF Dotti, Telmertpesat) [Fase “etaus, Dptihera: Petusis | O1070F Ta Taian 7 Hb Tieemhiue Muanzse pa E | COSTS | OTTO TATE Sa — PVOPL — aguNzoes | -caerTeee | sieTasa|_OaTeTore POV — Premise eonpals TaN Tiss, a Re TTT | TAT = Varela co Ss Te = _ = ‘Documentation Date_ a Percale an Vaccines receded Below this line are recommended. Recording of dates are optional. TT tumane Saaranis [ taeanee | oo" = ata Fa TCVEMPSVE Wei cama | BOTT TA i scart | Onna WEAN ine — Samar [ aneamis | oneeaaT | oe | raamanes | Ta [0 A) Patient Up to Date with tmmunizat [{1B) Patient-on-Catch Up Immunization ‘Schedule THIS SECTION CAN-EE COMPLETED BY CHILD CARG/SCIGOL WERDEN CARE PROVIDER psa erate = pao grate Nane + BOUCKARD-NILLER, BBN Parent/Guardian =— ‘STATENENT OF EXEUPTIONTOR LAW [ DECLARAGION RESPECTO A TAS EXENCIONES DE LA LEY DE VAGUNAGK 5: 8z passenra un snore oe iret FUE ai as PERSONAS BLENTAS er POMGA EN CUAAEIENAO SE LES EXCLUYA DELA ESCUELA Poa cer reen nr gered ca csemmarin or eres eee te ee Ea Ta ae SOTREMENTS | “ORRSH SCHOOL (6TH GRADE OR AIGHER) ie CPS Date 0910972014 eaooot heath au => — Date oF Birth + g1/2071995 = Medica exemption tothe fellowing vacel = {s'erencionporrazones maa api a ()siguente(s) vacuna(s): {signed (Firma) Date gaing/2016 Trtieierereyei ed = an — Physan ese) — HepB DTaP Tap Hib 1PV PCV MMR VAR. [Sxencion POR Thos RELdGO pace ones Sib Cds ie vou ita prance saraeapnac secpae le mmiean [Religious exemption tothe following vaccines): Exencion por mouves relgisos def) sigulene(s) vacunats): fstaned (Fime}—— Date ga192016 Cliverititiei eit) -— ——__{reche) Pat anton enenpte sauEsssEra HepB DTaP Téap Hib IPV PCV MMR VAR (Pate er eters ergs enenkment [PERSONAL ERE TON Pert pla she vamp pt a NGGRT WERT Dy POTTS OO NTESTE [ExencRN oR GRCENCUAS PERSCNALES Ins courcasputm spa ontor Go spenom arsctaca tous ta reapers rman, |stgned (Firms) — ‘Personal exemption tothe following vaccines) ‘Exoncion por creonclas personales de fa) siguleno() vacunats): oe bum ongaats Chet) titi ti cit Pat quater, manera Era me HepB DTaP Téap Hib IPV PCV MMR VAR Kiser Permanente: Bouchard-MiBse=Ben DOB: 01/20/1998 Printed at 9/9/16.9:16 AM “Reprod by RECO aa ak Tree Rav OTE I