CHILD MEDICAL STATEMENT FOR CHILD CARE

Please correct the errors described below.
  • This above named child has been examined, the immunization status recorded, and the child is in suitable condition for participation in group care.
  • This above named child has been immunized in accordance with the requirements of section 5104.014 of the Ohio Revised Code (please note any exceptions below).

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ATTACH A COPY OF THE CHILD'S IMMUNIZATION RECORD WITH DATES OF DOSES OF ALL IMMUNIZATIONS

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Optional Recommended Assessments/Screenings

Measurements

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