Health Information/Immunizations

Maine law requires every child care program to have on file an updated Certificate of Immunization for every child enrolled in the program. This certificate needs to be in your files within 30 days of admission to Country Fun Child Care and updated annually. Under the current law, children are required to have either vaccine administration records, laboratory evidence of immunity, or a physician’s note indicating they are medically exempt. Immunization records are maintained to ensure proper medical treatment is determined and given in the event of a disease outbreak or public health emergency.

Maine Child Care Immunizations Standards

Maine-AAP vaccination exemption form for child care.

If your child is not fully immunized, if there is an outbreak of a disease immunizations are required for, 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: