Program Medical Form - Amazon S3
Medical Form
Chrysalis Christian Preschool
TO BE COMPLETED BY CHILD’S PHYSICIAN
Child’s Name: ______________________________________________
Child’s Date of Birth: ________________________________________
Please list, with instructions, any medications taken routinely: _____________________
If special care is needed for allergies, diet, activity, or other chronic condition, please explain: ________________________________________________________________
Does this child have special needs: ____ yes ____ no If yes, please explain:_________
_____________________________ has been examined by me within the last 12 months and is physically and mentally able to participate in school activities.
Date of Examination: __________________________
By: ________________________________________
Physician’s Name
____________________________________________
Street Address
____________________________________________
City, State, Zip
____________________________________________
Phone number
_________________________________________ ___________________________
Physician’s Signature Date
COPYRIGHT © Messiah LC, Chrysalis Christian Preschool Rev 7/2009
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