4100 Millersburg Road Evansville IN 47725Friends Forever

Preschool

Today’s Date_________________

Child’s Name__________________________________________________________

Are child’s immunizations current?__________________

Is child healthy and able to attend schooland participate in all activities?_____________________

Doctor comments:________________________________

______________________________________________________

Doctor’s name:_____________________________________

Doctor’s signature:________________________________

Medical FormFax: 812.867.4080