Child Health Statement
For
Hill and Dale Child Development Center

Must be completed by a Doctor or RN within 30 days from the first day of attendance or the child cannot return until it is.

Child's Name: Birth Date: Parent's Name: Parent's Address:

For Doctor or RN use ONLY

Status of the above child's health:

Any known conditions under current treatment:

Child is capable of adjusting to programs of the child care facility:

Yes / No - Reason:

Signed

Date

(M.D. or RN)

Child Health StatementForHill and Dale Child Development Center