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My child has been examined within the past year by a health care professional and is able to participate in the day care program. Within 12 months of admission I will obtain a health care professional s signed statement and will submit it to the child-care operation. Name and address of health care professional Signature - Parent or Legal Guardian VISION R 20/ 1000 Hz PASS FAIL DATE SIGNATURE HEARING R L HEALTH REQUIREMENTS Name of Child Date of Birth Age Vaccine Birth 1 mos 2 mos 4 mos 6...
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