Child Health Statement
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.

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:



(M.D. or RN)