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HEALTH RECORD FOR CHILDREN IN DAY CAMPS & INTERSCHOOL & YOUTH CENTERS (This side to be filled in by parent before presentation to physician) NAME OF PROGRAM / CHILD IS LAST NAMEFIRST NAME/BIRTHDATEHome

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What is this side to be?

This side is a form for reporting income and expenses for a specific period.

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You can fill out this side by providing accurate information about your income and expenses for the designated period.

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The purpose of this side is to accurately report income and expenses for tax or financial purposes.

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You must report all income sources and expenses incurred during the specified period.

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