Physicians Health Statement

Diana's Lil' Darlings In Home Family Childcare

Where Children Come First

Child's Name: _________________________________  Birth Date: _______________________________

Parent's Name _________________________________________________________________________

Parent's Address ________________________________________________________________________

(This section to be filled out by child's physician)

Status of above child's health _____________________________________________________________

Any known condition under treatment ___Yes   ___No   If yes explain: ______________________________

Child is capable of adjusting to programs of the childcare facility. ____Yes   ___No

Signed: _____________________________

            (MD or RN)

Parent or guardian agree for provider to consult with a nurse or a physician in regards to child's health as needed for clarification.  In the event that we should have questions regarding the health of any child, we may contact child's listed physician for information.

Parent's signature _________________________    Date _______________________________

Back to Home Page

Back to Home Page