Day Care Admission Requirement
for Pre-School Age Children
In order for your child to be admitted to the Day Care Center, you
must have your child examined by their doctor and secure his
signature on this form and return it to the day care office by no
later than _________________________________.

Child's Name: _______________Date of Birth: ______________

_______________________________        ______________________
Signature-Parent or Legal Guardian                  Date

Name of Physician

Address of Physician's Office

Physician's Office Phone Number
                                               Physician's Statement

I have examined the above named child within the past year and find that he/she is
physically able to take part in the day care program.

_______________________________________________    _________________
Physician's Signature                                                                                Date