Family Child Care Enrollment Packet Face Sheet (Page 8 of 8) in pdf

Dear Physician: __________________________________________________________________

(Child's Name)

is enrolled in a family child care home which is licensed by the Department of Early Education and Care.

The Department of Early Education and Care’s regulations require at the time of admission a written

statement from a physician as evidence of each child's annual physical examination, immunizations and

lead screening in accordance with Department of Public Health's recommended schedules. A prompt

response is appreciated.

Evidence of a physical exam is valid for one (1) year from the date the child was examined and must be

renewed annually thereafter.

IDENTIFICATION

Name of Child: ______________________________________ Date of Birth: _____________________

Address: ________________________________________________ Phone # ____________________

Name of Parents: _____________________________________________________________________

Address: ____________________________________________________________________________

Date of Examination of Child: ___________________________________________________________

What is your opinion concerning the child's general health and appearance:

___________________________________________________________________________________

Has this child been screened for lead poisoning?

Yes ________ No _________

(*At least one (1) time between ages 9-12 months; Annually-Ages 2 & 3; at Age 4 if High Risk for Lead Poisoning)

If Yes, date screened: _______________

Does this child have any disabilities or chronic medical problems (allergies, limited vision, etc.) which

require special consideration or care by the child care educator? If so, please detail below:

____________________________________________________________________________________

Physician's Signature: _______________________________________Date: ______________

Comments: __________________________________________________________________________

____________________________________________________________________________________

Please return this form and the child’s immunization record to:

_____________________________________

P a g e

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FCCEnrollmentPacket20110406

Family Child Care Enrollment Packet Face Sheet Page 8