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ANGELS UNLIMITED PRESCHOOL
615 W 5th ST
RED WING MN 55066
651 385 8133

HEALTH INFORMATION

 

NAME: ________________________           DATE: ______________________

DATE OF BIRTH: ____________________

NAME OF PARENT/ GUARDIAN: _________________________________________

Minnesota Statutes 1988. Section 123.70 requires that all children who are enrolled in a Minnesota school be immunized against diphtheria, tetanus, pertussis, polio, measles, mumps, and rubella allowing for certain specified exemptions.  This form is designed to provide the school with information required  by the law and will be available for review by the Minnesota Department of Health and the local community health board.

Enter the month,  day and year in which your child received each of the following vaccines. A copy of your child’s clinic vaccine file may be used.

Type  vaccine     1st dose        2nd dose          3rd dose           4th dose           5th dose

DPT (diphtheria,

Tetanus,pertussis)______________________________________________________________________________

Polio___________________________________________________________________

HIB____________________________________________________________________

Hepatitis________________________________________________________________

MMR (measles, mumps,rubella)__________________________________________________________________________________

Varicella_(chicken pox)____________________________________________________________________________

Pneumonia_______________________________________________________________________

*IF YOUR CHLD DOES NOT RECEIVE THE ABOVE IMMUNIZATIONS DURE TO HEALTH OR RELIGIOUS REASONS, CONTACT SCHOOL FOR A WAIVER FORM.

Does your child have any known allergies? (i.e.: food, drugs,stings etc.)___________

Does your child take any medications?_________________

Are there any learning concerns I should watch for?______________________________

Is there a condition that may limit participation in :

Classroom activity:________________            Physical Activity: _____________________

Any other  Health/ Medical information you would like to share: ________________________________________________________________________

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