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Documentation of Varicella Disease
Documentation of Varicella Disease
(To be filled out by the parent, guardian, or medical provider of the child/student. Print out and return to school nurse.)
This document is being submitted on behalf of:
_____________________________________________________________
(Name of child/student) (Birth date of child/student)
I ______________________________________ verify that the above listed
(Parent/guardian/medical provider)
child/student had the varicella disease in __________ (year).
________________________________________
(Signature of parent/guardian/medical provider)
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