CHILD MEDICAL STATEMENT Date of Examination: Child's Name: Date of Birth: Height:

Weight:

Limitations or Health condition (including allergies, medications,dietary restrictions)

Immunizations: Complete for age: In Process

Circle one: Yes No Yes No

Exempt from Immunizations: Religious conviction Yes Health concern Yes

No No

This child has been examined and is in suitable conditon to participate in group class/care. Signature of examining Physician/Physicians Assistant/Advanced Practice Nurse

Physician's Address: Physician's Phone Number:

Parent/Guardian: Please attatch immunization record to this form. Thank You!

(circle one)