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California Pre-Kindergarten and School Immunization Record
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* Indicates required question
Guardian/Parent's Name
*
Your answer
Child's Full Name
*
Your answer
Statewide Student Identifier
*
SSID
Your answer
Ethnicity
*
Hispanic/Latino
Non-Hispanic/Non-Latino
Race
*
African-American/Black
American Indian/Alaska Native
Asian
Native Hawaiian/Other Pacific Islander
White
Other
Birth Date
*
MM
/
DD
/
YYYY
Sex
*
Female
Male
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