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This is Jess's play accessibility form

The personal information collected on this form will be used for the purpose of service plan and evaluation and will be treated confidentially in compliance with the Freedom of Information and Protection of Privacy Act. Any questions about the  collection, use or disclosure of this information please contact the Director, Provincial Deaf and Hard of Hearing Services at (604) 660-1800 (voice), (604) 660-1807 (TTY), 4334 Victory St, Burnaby BC, V5J 1R2.

This section to be completed by doctor.

Please attach a copy of your child/youth's immunization record.
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4-6 years of age
Date of Immunization
Date of Immunization MM/DD/YYYY
11 year of age (Grade 6)
Date of Immunization MM/DD/YYYY
Date of Immunization MM/DD/YYYY
Date of Immunization MM/DD/YYYY
Date of Immunization MM/DD/YYYY
14 year of age (Grade 9)
Date of Immunization MM/DD/YYYY
Date of Immunization MM/DD/YYYY
Date of Immunization MM/DD/YYYY
Other Vaccinations
Tuberculosis Testing (Required)
MM/DD/YYYY

Date Signed MM/DD/YYYY
Doctors's Signature
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