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<p style="margin-bottom:150px;">I, ________________________________________________, request a waiver of requirements for the following immunization(s) and or CPR, and include a signed statement from my primary care provider if for medical reasons:</p> | |||
<p style="margin-bottom:150px;">for the following reason(s):</p> | |||
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<td>________________________________________________________________________________________</td> | |||
<td width="75px"> </td> | |||
<td>_______________________________</td> | |||
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