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* 1. Date of Birth (Must bring I.D.)

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* 2. Your Information

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* 3. Age

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* 4. I have one of the following conditions (must bring a vaccine order from your healthcare provider)

Cerebral palsy; spina bifida; congenital heart disease; type 1 diabetes; inherited metabolic disorders; severe neurological disorders. including epilepsy; severe genetic disorders, including Down syndrome, fragile X syndrome, Prader-Willi syndrome, and Turner syndrome; severe lung disease, including cystic fibrosis and severe asthma; sickle cell anemia; and alpha and beta thalassemia.

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* 5. I live in

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* 6. Will you need assistance from a household member to attend a vaccine clinic?

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