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District Information|New Students>>Chicken Pox Verification

November 01, 2012

Texhoma ISD

Chickenpox Verification

Texas Law requires that all histories of chickenpox illness be supported by a written statement by a physician or the child's parent/guardian.  Please complete the following information.

This is to verify that ___________________________________________________________

(Name of Child)

has had chickenpox ____________ has had the varicella vaccine_____________

on this date _________________________________________.

 

__________________________________________            ____________________________

Signature of Parent/Guardian                                            Date

 

 

 

DECLARACION VARICELLA

La ley de el estado de Tejas se requiere que le informacion de las varicella.

Por favor de escribe la informacion.

 

Estos par confirmar que mi hijo(a) _________________________________________________

Nombre de estudiante

Tuvo las varicella _________________     tuvo la vacuna _________________

En esta fecha ___________________________________

 

_________________________________________________         ____________________________

Firmar de padres con custodia legal                                        Date

 
 

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