Health Information/Immunizations

The State of Maine requires a copy of your child’s official immunization record be kept on site as part of your child’s record.

If you have made a decision to not have your child immunized, you will need to supply a signed letter from your doctor stating that medical contradictions exist. Please note, if there is an outbreak of a disease immunizations are required for, that you will be responsible for keeping your child out of the program until it is safe for him/her to return. There will be no change in fees owed for this time out of the program.


Name of Child:                                                         DOB:                    

Child’s health history and current health problems:

Any special medical conditions, including chronic health problems:

Any special medications and/or restrictions:

Are your child’s immunizations up to date? Yes or No (circle) lf not, what is needed?

Has your child had any of the following common childhood illnesses?

  • Chicken Pox    yes / no
  • Measles    yes / no
  • Whooping Cough   yes / no
  • German measles     yes / no
  • Mumps   yes / no
  • Rubella   yes / no
  • Scarlet Fever    yes / no
  • German measles    yes / no
  • Rheumatic Fever    yes / no

Is your child prone to:

  • Ear Infections    yes  / no     
  • Headaches   yes  / no           
  • Sore Throats    yes  / no
  • Stomach Upsets    yes  / no    
  • Colds      yes  / no                  
  • Upper Respiratory Infections    yes  / no  
  • Diabetes   yes  / no  
  • Heart Disease    yes  / no  

Last tetanus shot:     /     /    Reaction?:   Yes / No

Other:

Does your child have any speech, hearing, or visual problems?

Has your child ever been tested for speech, hearing, or visual problems? Yes / No (circle) If yes, describe:

Has your child ever had any surgeries? Yes / No ( circle) If yes, describe on back –

Known medical problems:

Drug Reactions:

Allergies: (food, environment, drugs, hygiene products)


Permission for application of sunscreen has been signed Yes / No


Legal Guardian Signature:   

Print Name:

Date: