Statement of Health Form

Health Statement
To be completed by a parent.
Child's Full Name*
Child's Birthdate*
Significant illnesses and surgeries child has had (give age at time.)*
Any special health-related needs of child (allergies, medications, injuries, etc.)*
Physical Assessment
Is there any defect of vision, hearing or speech of which the child care program should be aware, or could compensate by appropriate action?*
Is this child subject to any conditions which limit classroom activities or physical education?*
Is this child subject to any condition which may result in an emergency situation?*
Is this child subject to any mental or physical condition for which he/she should remain under periodic medical observation?*
Other information you would like to share:
FOR CENTERS SERVING SCHOOL-AGE CHILDREN OPERATING IN THE SAME SCHOOL FACILITY IN WHICH THE CHILD ATTENDS SCHOOL: My indication below certifies that immunization information concerning my child has been provided and is available in the school file.
Families of children not currently enrolled in West Marshall K-5 (including those in preschool) are required to supply signed copies of their child's most recent physical exam and immunization record.
Immunization information is on record with West Marshall elementary school or has been provided to child care coordinator.*
Electronic Signature of Parent or Legal Guardian*
Date*

Health Statement