In the event I cannot be reached to make arrangements for emergency medical care, I authorize the person in charge to take my child to:
I give consent for the facility to secure any and all necessary emergency medical care for my child.
Work to for School and home,
I have provided the childcare operation with a copy of my child's most current immunization record.
If Your Child does not attend pre-kindergarten or school away from the child -care operation, one of the following must be presented when your child to the child-care operation or withinn one week of admission.
HEALTH TH-CARE PROFESSIONAL'S STATEMENT: I have examined the above-named child within the past year and find that he/she is able to take part in the care in the day care program.
A signed and deleted copy of a health care professional's statement is attached.
Medical diagnosis and treatment conflict with the tenets and practices of a recognized religious organization, which I adhere to or am a member of I have attached a signed and dated affidavit stating this.
My Child has been examined within the past year by a health care professional and is able to participate in the day care program.within 12 months of admission.i will obtain a health care professional's signed statement and I will submit it to the child-care operation
Varicella (chickenpox) vaccine is not required if your child has had chickenpox disease. If your child has had chickenpox, please complete the
I am excluding my child from the immunization requirements for reasons of conscience, including a religious belief. I have attached an official notarized affidavit form developed and issued by the Department of State Health Services. I understand this affidavit is valid for 2 years.
TLC on Hedgcoxe
5200 Hedgcoxe Road
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