Kids of the Kingdom Episcopal School

   Where Children Know They are Loved by God

Medical Form

Child’s Name__________________________________Sex________Birth date__________

PLEASE BE ADVISED: Doctor’s Statement must be signed and a current copy of your child’s shot record on file, before your child may begin the program. All immunizations must be kept up to date or your child will be excluded from attendance.

DOCTOR’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

*Hearing & Vision Screenings are required for children enrolled in the 4 year old classes. Results may be recorded at the end of this form.

PARENT/GUARDIAN: Please write yes or no to all special problems or needs listed below. If your answer is yes, please explain in detail.

Child's Health Statement
 Write Yes or No
 If Yes, please explain in detail
 Food Allergies
 Existing Illness
 Previous Serious Illness
Injuries and hospitalizations over the past 12 months 
 Any medications prescribed for long-term continuous use
 Disabilities/Special Needs
 Any other information which the staff should be aware of

Child daycare operations are public accommodations under the Americans with Disabilities Act (ADA), Title III. If you believe that such an operation may be practicing discrimination in violation of Title III, you may call the ADA Information Line at (800) 514-0301 (voice) or (800)-514-0383 (TTY).

______________________________________________________           ____________________

Signature – Parent or Legal Guardian                                                        Date


Child’s Name_________________________________Sex________Birthdate___________

Visual acuity and hearing sensitivity screening are required only for children enrolled in the 4-year-old classes. Rescreening is only required if an abnormality was noted on the first screening. Speech screening is optional (not required).


Hearing Screening

At 25db
 At 25db
 500 Hz
 500 Hz
 1000 Hz
 1000 Hz
 2000 Hz
 2000 Hz
 4000 Hz
 4000 Hz

________________________________                      _______________________________

Signature                                                                          Signature


1ST Distance                                                                  2ND Distance

ACUITY: R-20/_________ L-20/_________                      ACUITY: R-20/_________ L-20/_________

PASS______________________                                      PASS______________________

FAIL-RESCREEN___________      ___________               FAIL-REFER___________      __________

                                                     DATE                                                                           DATE

_____________________________________                    _________________________________

Signature                                                                               Signature


NAME OF TEST: _______________________________________________________________________

________PASS      __________FAIL

__________________________________________________            _____________

Signature                                                                                                 Date