MENOMONEE FALLS PRE-SCHOOL CO-OPERATIVE

CHILD’S HEALTH AND IMMUNIZATION RECORD

 

Child’s Name (First, Middle, Last):                                                                                                       

Street Address:                                                                                                                                     

City/State/Zip:                                                                                                                                       

Telephone Number:                                                    Child’s Date of Birth:                                         

Father’s Full Name:                                            Mother’s Full Name:                                                   

Class Assignment:       2-day am       2-day pm      3-day am       3-day pm Term beginning               

STATE LAW REQUIRES

That each student shall have a physical within the 12 months before the first day of school,

and every 2 years thereafter. 

This form is due no later than your child’s first day of school.

I have examined the above-named child and find him/her to be in good health for enrollment in a pre-school program, except for the following special needs, if any:

SPECIAL NEEDS:

            Physical                                                                                                                                                    

            Speech                                                                                                                                                         

            Behavior:                                                                                                                                                    

            Allergies (including food)                                                                                                                      

            Other                                                                                                                                                         

IMMUNIZATION HISTORY

Date of vaccination

VACCINE

1ST

2ND

3RD

4TH

DTP/DtaP/DT

 

 

 

 

POLIO

 

 

 

 

MMR

 

 

 

 

HepB

 

 

 

 

HiB

 

 

 

 

Varicella

 

Or date of having chicken-pox:

Or waiver for reason:

 

 

                                                                                                                                                                       

Date of Examination                                                                  Signature of Physican

Return Completed Form To:  Menomonee Falls Pre-School Co-Operative, PO Box 283, Menomonee Falls, WI  53052-0283