Rumck Health Certificate printable pdf download

Rumck Health Certificate

RUMCK Health Certificate

Roswell United Methodist Preschool & Kdg.

Telephone: 770.998.8699

814 Mimosa Boulevard

Fax: 678.832.1108

Roswell, GA 30075

All students are required to submit an

All students are required to submit a completed

immunization record and the RUMCK

Georgia Immunization form #3231.

health certificate on or before the first

day of school.

Children turning age five before school begins

A child’s health certificate must include

are also required to submit immunization form

results of a health exam completed

#3231 and ear, eye, and dental form #3300.

within six months of the beginning of

school.

Date: _____________________________

Child’s DOB: __________________________

This is to certify that ____________________________________________ is free of infection or

any contagious disease and may participate in all school activities.

Childhood diseases:

__________________________________________________________

Allergies:

__________________________________________________________

Operations/Dates:

__________________________________________________________

Is there any other information that would give us a more complete picture of this child’s health?

______________________________________________________________________________

Date of last examination:

_____________________________________________

Next immunization due (month/year):

_____________________________________________

Physician’s Signature:

______________________________________________________

Rumck Health Certificate