2008-2009

 

This is to certify that  ______________________________Birthdate________

 has been given the following immunizations.

                                                       INITIAL                 BOOSTER 

DPT                                        1. _____________     _____________

                                                2. _____________     _____________

                                                3. _____________     _____________

 

DT                                           1. _____________     _____________

                                                2. _____________     _____________

                                                3. _____________     _____________

 

IPV                                          1. _____________     _____________

                                                2. _____________     _____________

                                                3. _____________     _____________

 

Measles                                  1. _____________     _____________

Rubella                                   1. _____________     _____________

Mumps                                   1. _____________     _____________

 

HIB                                         1. _____________     _____________

                                                2. _____________     _____________

                                                3. _____________     _____________

 

Hep B                                     1. _____________     _____________

                                                2. _____________     _____________

                                                3. _____________     _____________

 

Varivax                                   1. _____________     _____________

 

Hep A                                     1. _____________     _____________

Other                                      1. _____________     _____________                                                                     

Tuberculin                              Positive ________    Negative __________

MANDATED SCREENING FOR FOUR AND FIVE YEAR OLDS:

 

Vision: With glasses _____ Without glasses ____ Passed _____ Failed _____             

                                                                                                       Referred _____

Hearing: Passed ____  Failed ____  Referred _____

 

I have examined the above named child within the past year and find that he/she is free of infectious and contagious disease and is physically and mentally able to participate in group activities.

 

__________________________________________  Date____________________

Physician’s Signature