in-home family day care center
Children under twenty-four months of age will be given a physical exam every six months after admissio to day care. Children over twenty-four months in day care will be given a physical exam at least every two years after admission.
Parent or guardian-complete this section.
_________________________________________________________________________________________
Name_child:
Address-child:
Birthdate-child:
Name-parent or guardian:
Address-parent or guardian:
health professinoal-complete this section:
_________________________________________________________________________________________
Instructions for feeding and care of child with secial needs, including allergies-specify:
Immunization(s) not to be administered to child due to medical reasons-specify:
Authorization:
I certify that I have examined the above child on this date and that he/she is able to participate in day care activities.
Name-health care provider:
Address:
Signature-health care provider:
Date of examination:
I will also need a copy of your child's immunization record for their file. Thank you!