If yes, please describe :Are your child's immunizations current? YesNo | If no, please fill out the immunization exemption form.
Immunization Exemption Form | Allergies, food or otherwise:YesNoIf yes, please explain:Asthma:YesNoHas had Chicken Pox:YesNoDoes your child have Diabetes?YesNoIf yes, treatment for us to use:Ear Infections:YesNoComments: Epilepsy/Seizures:YesNoTreatment for us to use: Comments: Emotional Issues/Behaviors:YesNoBest Methods for us to use: Situation of Cause: Measles: YesNoMumps: YesNoUrinary Problems: YesNoComments: Whooping Cough: YesNoTreatment for us to use: Any Communicable Diseases (genital herpes, & etc.?) YesNoIf "Yes", Please List:Special considerations due to general physical condition: Doctor: Phone: Date of last Physical Exam: Is child currently taking medication? YesNoIf "Yes", Please List:Other helpful information: | Please upload any necessary documentation, including the immunization exemption form, if you filled one out. | File Upload 1File Upload 2 |
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