Medical Statement Template Of Child In Childcare (Page 2 of 2) in pdf

Medical Statement Template Of Child In Childcare Page 2

OCFS-LDSS-4433 (Rev. 4/2008) REVERSE

Medical Statement of Child in Childcare

(continued)

Health Specifics

Comments

Yes

Are there allergies? (Specify)

Is medication regularly taken?

(Specify drug and condition)

Yes

Is a special diet required?

Yes

(Specify diet and condition)

Are there any hearing, visual or dental

Yes

conditions requiring special attention?

Are there any medical or developmental

Yes

conditions requiring special attention?

Summary of Physical Exam

Include special recommendations to Day Care Providers

On the basis of my findings as indicated above and on my knowledge of the named child, I find

that: he/she is free from contagious and communicable disease and is able to participate in day

Yes

care.

Signature of Examiner

Address

Please Print Name

City, State, Zip

(

)

Title

Phone

Date

Religious Exemptions

Public Health law Section 2164 allows a child to be religiously exempted from immunization. A written and signed

statement from a parent, parents or guardian of the child stating that they object of the immunization of their child due

to their sincere and genuine religious beliefs should be submitted to the day care owner, operator or administrator who

shall determine whether the statement of religious belief is acceptable.

Medical Statement Template Of Child In Childcare Page 2