Medical Form/vaccination Record Form printable pdf download

Medical Form/vaccination Record Form

Peace Montessori

2017-2018 MEDICAL FORM/VACCINATION RECORD

Fax: 260.493.9089

To be completed by parent:

Child’s name: _______________________________________________________________ Birth Date: ___________________

Address: ___________________________________________________________City:__________________________________

State: _________________ Zip: ____________________ Phone: ____________________________________________________

Parent Signature: ___________________________________________________________________Date____________________

To be completed by Physician:

Please complete dates of completed immunizations and fax back to the number listed above

DTAP:

Polio Shot

Hep B Series:

HIB:

(please specify):

Varicella:

MMR:

Does the child have any record of serious illness, injury or surgery? _________________________________________________________

_______________________________________________________________________________________________________________

Does the child have any allergies or dietary restrictions? Please list. ________________________________________________________

_______________________________________________________________________________________________________________

In your opinion, is the child able to participate fully in school activities? _____________________________________________________

Please list any medication(s) the child is currently taking. _________________________________________________________________

_______________________________________________________________________________________________________________

Other comments:

_________________________________________________

Physician’s signature

Medical Form/vaccination Record Form