DAYCARE MEDICAL AND HEALTH FORM

Child's Name: __________________________________________________________Date: __________________

All children must meet the minimum state vaccine requirements.  If you need more information about the minimum requirements, please contact me.

ADMISSION REQUIREMENT: When your child is admitted to our daycare, you must complete and present this form along with a copy of an immunization record signed or stamped by a physician or health professional.

Note: If medical diagnosis and treatment and/or immunizations conflict with your religious beliefs, you must sign an affidavit to that effect and attach it to this form.

If immunization would be injurious to your child or family, you must obtain a certificate (signed by a physician) to that effect and attach it to this form.

Please sign and date one of the following:

Doctor's Statement: _______________________________________________________________________________
________________________________________________________________________________________________

I have examined the above-named child within the past year and find that he/she is physically able to take part in this program.

Physician's Signature:_____________________________________________________________________________

My child has been examined within the past year by a licensed physician and is able to participate in this program. Within the next 12 months, I will obtain a physician's statement and submit it to the school.

Parent's Signature Date:___________________________________________________________________________