|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
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