Dear Physician: ______________
__________________is enrolled at Wareham Child Care an early childhood
program licensed by the Department of Early Education and Care. The Department
of Early Education and Care’s regulations require at the time of admission a
written statement from a physician as evidence of each child's annual physical
examination, immunizations and lead screening in accordance with Department of
Public Health's recommended schedules. A prompt response is appreciated.
Evidence of a physical exam is valid for one year from the date the
child was examined and must be renewed annually thereafter.
IDENTIFICATION
Name of Child: _____________________ Date of Birth: ___________________
Address: ________________________________________________
Phone # ____________________
Name of Parents: ________________________________________________
Address: _________________________________________________________
Date of Examination of Child: ________________________________________
What is your opinion concerning the child's general health and
appearance:
________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
Has this child been screened for lead poisoning? Yes ________ No
_________
If Yes, date screened: _______________
Does this child have any disabilities or chronic medical problems
(allergies, limited vision, etc.) which require special consideration or care
by the child care provider? If so, please detail below:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Physician's Signature: ____________________________________
Date: _________________ Comments: ____________________________________________
________________________________________________________________________________________________________________________________________________________
Please return to:
Email: carol@warehamchildcare.org FAX:
508-295-0679
Phone: 508-295-1734