Get your registration packet here!

Join the fun!
Register now
How to enroll:
 Read this packet carefully
 Complete all forms (pages 11 – 17)
 Submit all forms and fees (deposit +
registration) to one of our offices:
o CCC at Harriman Campus, Building 4
o U-Kids in Dutch Quad
 Forms may be mailed, but be aware
our mail is not collected daily. Our
mailing address is:
PO Box 3701 Albany NY 12203
Disclaimer: Parents are always welcome to visit our camp at any time, but sorry —parents cannot enroll in camp!
Summer Fling is a traveling day camp. The campers spend much of their time
away from the home base of the camp on daily field trips. (There may be a day or two during
the summer that instead of a daily trip we bring in special programming.) Our trips include state
and local parks, amusements, museums, and other hot spots. Each week there are also a
variety of games, crafts, cooking, swimming, and more. We use chartered school buses for
transportation. The Harriman State Office Building Campus site is based out of Building Four.
The University at Albany site is based out of the uptown campus of SUNY Albany.
The camp is required to obtain and maintain a permit to operate from the Albany County
Department of Health. There are a minimum of two camp inspections annually. Copies of these
reports are maintained on file with the Albany County Department of Health located at 175
Green Street, Albany, New York. The camp is only in operation during summer vacation.
Age Qualifications
The camp is open to children that have completed kindergarten through 8th grade.
Kindergarteners must have been 5 years old prior to December 1, 2014. Children exiting 8th
grade must not be older than 14 as of December 1, 2014. Children are enrolled regardless of
race, color, gender, religion, or national origin.
Priority for Enrollment
A five calendar day priority period, beginning with the dissemination of camp materials, is given to
University employees and students at the U Albany site, and OGS employees at the SOBC site. Priority
is given to OGS and U Albany faculty, staff and students who have children currently enrolled in one of
our centers as well as to OGS and U Albany faculty, staff and students who have children that are an
alumni of one of our programs; then to OGS and U Albany faculty, staff and students; then to children
of NYS employees; then to the community. (Please ask if you need more information on this policy.)
Tips for Ensuring Your Child’s Success at Summer Fling
Summer Fling is a recreational traveling day camp. It is designed to allow the campers to meet
new friends and have lots of summer fun. We have lots of special activities, and campers are
encouraged (but not forced) to participate. Campers are always supervised by the staff, but
there is less structure than is found in school.
Your child can be successful and extremely happy at Summer Fling if they can:
 Participate in large and small group activities with loose structure.
 Be responsible for their belongings.
 Follow staff directions.
 Interact appropriately with peers and adults.
If you children requires medications to be successful in school, they will need them when they
are in camp.
Camp hours are 9:00AM-4:00PM, Monday thru Friday
We offer free extended care 7:30AM-9:00AM and 4:00PM-5:30PM
We are closed state holidays, ie. July 4th.
Summer Fling is typically scheduled to be on trips between the hours of 9:15 am AND 4:00 pm.
There are times when we do not return until after 4:30 pm. Campers must be here 15 minutes
prior to scheduled departure times.
If your child arrives after the group has left for their daily trip, additional transportation or care
for that child will not be provided.
We believe that time is a precious commodity to all of us. It is important that all children be
picked up by 5:30 pm. If a child is picked up after 5:30 pm, late pick up fees are charged.
Please see the section on fees for more details.
For those enrolling in Week 8 (August 17-21) at UAlbany only
At 5:00PM on Friday, August 21, 2015, all children remaining in the program will be taken to
our U-Kids site to wait for their parents to pick them up.
In the event of unforeseen circumstances requiring us to close, including but not limited to
non-essential staff being sent home, the closing of our buildings or other emergency closing;
buses will be recalled and parents must pick up their children. Late fees will be applied.
A $35.00 nonrefundable registration fee is due at the time of enrollment. As part of this fee,
each child that has registered prior to May 15, 2015 will receive a camp t-shirt.
A $25 (per child, per week registered) deposit is due at the time of registration. The deposit
is non-refundable and non-transferable. This deposit is applied toward each week’s tuition.
Tuition is $205.00 per week when pre-paid.
The weekly tuition fee is due by the Monday three weeks prior to the start of each camp week
(see chart.)
We accept payment via direct pay and through Paypal. The direct pay method includes cash,
checks, money orders, and SEFCU autowithdrawal. Paypal can be accessed from our web
site. Using Paypal results in a loss of the $6.00 per week direct pay discount.
Payment must be made payable to the CAMPUS CHILDREN’S CENTER and dropped off in
one of our offices or mailed to: PO Box 3701
Albany, New York 12203.
NO payments will be accepted by program leaders, lifeguards or counselors.
Please write the child's name on the memo line of all checks in order to ensure that proper
credit is given.
Week 1 –6/29-7/3
June 8, 2015
Week 2 – 7/6-7/10
June 15, 2015
Week 3 – 7/13-7/17
June 22, 2015
Week 4 – 7/20-7/24
June 29, 2015
Week 5 – 7/27-7/31
July 6, 2015
Week 6 –8/3-8/7
July 13, 2015
Week 7 – 8/10-8/14
July 20, 2015
Week 8 – 8/17-8/21
July 27, 2015
Week 9 – 8/24-8/28
(at CCC only)
August 3, 2015
Week 10 – 8/31-9/4
(at CCC only)
August 10, 2015
Direct Pay
Direct Pay
via Paypal
There is no grace period! Tuition not received by the pre-pay due date will result in loss of the
pre-pay discount. This results in an additional $25.00 charge or forfeiture of the slot if there is
a wait list.
Tuition for added weeks is due when the week is added or the tuition due date whichever is
A payment schedule will be included with your confirmation letter. Keep this schedule in a safe
place that will remind you to pay in a timely manner to avoid additional fees.
Cancellation Policies (These are new, please read carefully!)
1. If a parent/guardian cancels one or more weeks of camp BEFORE the close of
business on May 15, 2015 they will NOT incur the cancellation penalty. The $25
deposit/child/week will be retained by the CCC since it’s non-refundable and nontransferable.
2. If a parent/guardian cancels one or more weeks any time AFTER the close of business
on May 15, 2015 they will incur a $100/child/week cancellation penalty. The
cancellation fee is in addition to the $25 deposit/child/week.
3. If a parent/guardian cancels one or more weeks and the equivalent number of
weeks/child are added, the $100/week/child cancellation penalty will be waived.
Cancelled and added weeks require the submission of a completed cancellation/add form. This
form can be obtained from the CCC office.
There is a $25.00 fee for each returned check.
A fee of $5.00 per child is charged for every five minutes or part thereof that a child is picked
up past closing time. There is no grace period. A $10.00 administrative fee will be added to
each late pick-up fee starting with the fourth late pick-up. Once a family incurs the
administrative fee it remains in effect for the duration of the child’s association with CCC, Inc.
Parents/guardians who are late more than six times, may be requested to seek alternate care
that better meets their scheduling needs.
A fee of $7 or the cost of food, whichever is higher, is charged each time a child is without a
lunch and the camp provides one. A fee of $5 is charged each time a child is without a beverage
and the camp provides a reusable water bottle with water. A $10 administrative fee will be
added each day food is provided for a child starting with the fourth instance. Once a child incurs
the administrative fee, it will remain in effect for the duration of the summer.
All accounts are finalized in late September with any refunds due being mailed at that time.
Anyone with a balance due to us will be sent to our collection agency and the child/ren will no
longer be eligible to attend.
Summary Fee Chart
Deposit (number of weeks x $25.00 )
(non-refundable, non-transferable)
Pre-Paid Tuition with discount and direct pay
Non- Pre paid Tuition with direct pay
Cancellation Fee- after May 15, 2015 (per child per
Returned Check Fee
All families paying via the direct pay method receive this discount. Families
using paypal do not receive the direct pay discount. Contact the office for
more information.
Late Pick-up/each 5 minutes late or part thereof
Late Pick-up administrative fee, beginning with 4th occurrence
Lunch administrative fee, beginning with 4th occurrence
Water bottle and water
7.00 or cost
Registration begins immediately and closes at noon on the Tuesday prior to the actual camp
week or when the week is full, whichever is earlier. Confirmations will be mailed to all
In the event that a child becomes ill or injured while on a trip, parents will be required to pick
up their child from the trip location. Keep this in mind when deciding to send your child to
camp that day.
A child who is suspected of being ill or contagious may not attend the camp until all
symptoms have cleared, or we receive written notification from the child's physician that they
are no longer contagious and can return to the program. Symptoms of Suspected Illness:
Fever--101 degrees, lower if with other symptoms
Diarrhea--three occasions
Vomiting--one occasion
Rashes of suspicious origin
Unable to participate in the program
Medicines (This is under review by the Department of Health and may be revised.)
We encourage you to administer all medications to your child. If you are unable to, and it is
necessary that your child receive the medicine during camp hours, we will do so when:
We have received our medication form completely filled out and signed by you and your child’s
physician. These forms may be obtained from the main office or the camp site. Be sure to
have them completed well in advance.
We receive the medication in the original container and it is given to a counselor. For the
safety of all of the children, all medication must be stored in our first aid packs. Children are
not allowed to carry their own medications.
Physical Examinations and Immunizations
A physical form including a record of immunizations is required for each child.
Parents are expected to bring their child into the room, sign them in upon arrival and sign
them out at departure. Be sure that the child is under the supervision of the counselor before
leaving the premises. You must let the counselor know you have left your child with them.
Please be sure that you never leave your child unattended. Individuals picking up your child
must be at least 16 years of age and have a valid picture ID.
No child will ever be released to anyone other than the parent without prior authorization from
the parent, unless that person is listed as such on the enrollment application
In the event of an emergency, parents are contacted immediately. If for some reason we are
unable to reach either parent, then the emergency contact names and numbers you’ve listed
on the enrollment application will be notified. For this reason, we ask that you be sure to
keep us informed of any changes in your phone number(s). Additionally, if the child is unable
to participate in the group activities due to illness or injury, it is the parent’s responsibility to
pick up their child. Please be sure your emergency contact individuals are aware of their
responsibilities, accessible and available.
If the need to evacuate arises, you will be notified. Please be sure to provide us with updated
telephone numbers.
Accident reports are completed on all injuries observed and/or reported to the counselors
regardless of severity, e.g., bumps, bruises, scratches, etc. Parents are provided with a copy
of this report.
Sneakers or sturdy shoes are required for all activities. Sandals and flip flops are
dangerous during gaming activities and are NOT allowed for many activities and trips.
Sunburns are painful and dangerous. Counselors will remind and help the children to put their
sunscreen on but they cannot force a child to wear it.
The children are expected to conduct themselves in an appropriate manner. Our expectations
are developmentally appropriate and we realize that problems can occur. When this happens,
discipline must be a cooperative effort. It is important that we keep the lines of communication
open and work together to meet our goals.
Campers are expected to:
 Respect themselves, fellow campers, camp staff and property.
 Keep hands, feet, and objects to themselves.
 Listen to and follow directions given by the staff.
 Use appropriate language at all times with all people while at camp.
 Stay with their group at all times.
 Refrain from participating in behavior that is inappropriate to the camp setting.
 Refrain from bringing any weapons to camp.
If a child does not meet the expectations, we may use a variety of techniques including
discussion, removal from an activity, visits to the office, loss of privileges, parent discussions,
and suspension (part or full day) or expulsion.
Do NOT bring cell phones to camp.
Cell phones are disruptive to our program. Any child who does bring a cell phone will have the
phone collected by staff. It will be returned to the parent at departure.
All children and parents must sign a Behavior Contract and submit it with their enrollment
application. Children must sign their own Behavior Agreement.
The Campus Children's Center, Inc. reserves the right to disenroll a child, if their behavior is determined
to be detrimental to the program or if the health and safety of other children or staff are adversely affected.
Additionally, failure to keep your tuition account in good standing may result in your child’s disenrollment
from camp.
Parents must provide a nutritious bag lunch including a beverage every day. Be sure to pack
items that will remain safe to eat by lunchtime. DO NOT rely on money for snack bars, some
locations do not have them and some shutdown. Extra water and/or juice boxes must be sent as
the children spend most of their time outside.
When packing and unpacking lunches, please remember that with the excitement of activities
and the summer heat children's eating habits vary greatly. For our part, we encourage positive
eating habits and allow ample time for meals. We provide a morning and afternoon snack for
those children who are here at serving time.
a labeled nutritious lunch including beverages. For health and safety send extra water.
a labeled swimsuit and towel.
a labeled change of clothes.
a labeled backpack.
a pair of socks, We may change our plans to include an activity that requires socks.
clothing appropriate to the weather and activities.
sunscreen The first overall application should be done at home every morning.
insect repellent is optional, but we highly recommend it.
All belongings must be labeled with the child’s name. Staff are not responsible for children’s
personal items. If you choose to allow your child to bring any items of value, they may become
lost, stolen or traded (none of which is allowed.) Items that become disruptive will not be allowed.
Electronic devices will be confiscated by staff if there is any suspicion of questionable
material or behavior. Devices will be returned to the parent at departure following a discussion
of the incident. This may include an investigation of the material on the device.
Campers are divided into groups. This year we anticipate one older group and one younger group. The
groups are based on grade completed and the number of children enrolled in the program. The “age” of
the groups may change based on group size. (One group weeks 9 and 10.)
Transportation and admission fees are paid by the Camp for campers who have taken the bus. Additional
individuals or those being transported on their own are responsible for their own admission. Campers are
allowed to bring money for souvenirs, treats, etc., but are responsible for their money.
PLEASE CALL 457-3210.
Summer Fling 2015
We are looking forward to an exciting summer, packed full of fun and adventure. Below is a brief description of each
week’s theme and trips. Some activities may need to be rescheduled, and much more will be added!
Week #1 (June 29 – July 3)
Happy Everything
Join us we celebrate a different holiday every day! It’s Halloween and more… all in one week! We’ll round out our super
happy week with a trip to one of Summer Fling’s Happiest Places—The Great Escape!
Week #2 (July 6 – 10)
Under The Big Top
Step right up! It’s circus week at Summer Fling, and we have trips and activities that are bound to amaze and astound
you! We’ll take in a Circus Smirkus show, visit Zoom Flume, and have three rings of fun!
Week #3 (July 13 – 17)
Candy Crush
We’ll have a sweet week, as we experiment with candy, play with candy, make candy… oh yeah, and EAT CANDY! The
Younger Group will relish Magic Forest and the Older Group will eat up Lake George Day!
Week #4 (July 20 – 24)
Summer Fling Saves the Day
We’re superheroes this week! While we may not be able to scale buildings in a single bound, we can have fun at the
Saratoga Fair!
Week #5 (July 27 – 31)
Shiver Me Timbers
Arrrgh! Ahoy buccaneers! If it’s fun ye be lookin’ for, then weigh anchor— the Older Group will brave the rapids White
Water Rafting, and the Younger Group will meet the beasts at Adirondack Animal Land!
Week #6 (August 3 – 7)
Lego Mania
This week is for those who imagine a miniature world constructed of colorful, clicking bricks and populated by teeny
plastic people. Even with our engineering endeavors, we’ll still have time to enjoy a day at Bosquet Mountain and
another at the Schoharie County Fair!
Week #7 (August 10 – 14)
Wacky Week
This week is as wacky as we can make it! Crazy Hair Day is just one example of the wackiness we have planned! Our
summer wouldn’t be complete without a visit to the Altamont Fair!
Week #8 (August 17 – 21)
I Spy
This is our top secret week of camp fun. We can’t tell you much—but what we can tell you is that it’s going to be SO
MUCH FUN! While solving the clues, we’ll also take a Mystery Trip!
Week #9 (August 24 – 28)
Millions of Minions (CCC only)
Summer Fling is winding down— but there’s still time for plenty of minion fun! We’ll go Up Yonda to get up close and
personal with nature!
Week #10 (Aug 31 – Sept 4)
Final Fling (CCC only)
We’ll say farewell to the summer of 2015. While we’ll visit beaches at state parks this week, we may not be able to
swim. We’ll end this awesome summer with a barbecue and a visit to the Chatham Fair.
Campus Children’s Center, Inc.
Summer Fling
Enrollment Application 2015
Please print neatly and place a star next to the phone number you would like us to call first
Child’s Name:____________________________________________ Birth Date__________________
Home Phone:__________________________________
M /
Parent’s Name:________________________________________ Social Security _________________
Home #:___________________ Work #:____________________ Cell or Pager#:________________
Employer Name and Address:___________________________________________________________
Parent’s Name:________________________________________ Social Security _________________
Home #:___________________ Work #:____________________ Cell or Pager#:________________
Employer Name and Address:___________________________________________________________
Pediatrician:____________________________________ Phone Number:_______________________
Best email address to send information to:[email protected]______________________
Emergency Contact and Departure Authorization
An emergency contact is someone we will notify in the event of an emergency if you cannot be reached. Emergency contacts have
departure authorization. Under NO circumstance will a child be released to anyone without authorization from the parent or legal
guardian, unless they are listed below. Please list daytime phone numbers. If you are having someone listed below pick up your child,
please make them aware they will need a photo ID with them.
Name:__________________________ Phone:___________ Relationship:_____________
Name:__________________________ Phone:___________ Relationship:_____________
Name:__________________________ Phone:___________ Relationship:_____________
Parent’s Union Affiliation:_____________
Parent’s Union Affiliation:_______________
Do any of the Child’s Grandparents have State or SUNY affiliation? Yes_______ No______
If yes, please specify:________________________________________________________
Signature of Parent/Legal Guardian:_________________________________ Date:________________
Signature of Parent/Legal Guardian:_________________________________ Date:________________
Join us on Facebook (
Week / Site Selection Form 2015
Child’s Name:___________________________________
Date Of Birth:___________________________
Grade COMPLETED in June 2015: _______________
If your selected site is full, can you put you at the other site? _____YES
Please circle your site preference for each week you are enrolling:
Week 1 (June 29-July 3)
Happy Everything
Week 2 (July 6-10)
Under The Big Top
Week 3 (July 13-17)
Candy Crush
Week 4 (July 20-24)
Summer Fling Saves The Day
Week 5 (July 27-31)
Shiver Me Timbers
Week 6 (August 3-7)
Week 7 (August 10-14)
Wacky Week
Week 8 (August 17-21)
I Spy (UAlbany site closes on 8/21)
Week 9 (August 24-28)
Color Me Summer Fling
Week 10 (Aug 31-Sept. 4)
Final Fling (CCC Site Only)
(CCC Site Only)
TOTAL number of Weeks Selected
$25.00 per week deposit
________ Deposit total
$35.00 Non-refundable registration fee
Amount due at registration
For more information about these fees refer to the Parent Handbook or call 518-457-3210.
I/We ______________________ _______ the parents/guardian of _____________________ agree to the
1) To pay a $35.00 non-refundable registration fee for each child upon enrollment in the Campus
Children’s Center, Inc. Summer Fling program. __________Initials
2) I/We give permission for our child(ren) to participate in all camp activities including but not
limited to swimming at Grafton, Saratoga, Moreau State Parks and other locations.
3) I/We agree to adhere to all other policies and procedures put forth by the Board of Directors and
Administration of the Campus Children’s Center, Inc. _________Initials
4) I/We agree to pay all fees and other monies owed to the Campus Children’s Center, Inc.
5) I/We agree in the event that the Campus Children’s Center, Inc. experiences an unplanned
closing, the busses will be recalled and I will be required to pick up my child(ren) immediately.
6) I/We agree to send a nutritious lunch and beverage with my/our child(ren) every day that it is
required. Additional fees will be charged if the CCC provides food and/or water.
7) I/We understand that if my/our child(ren) brings any items of value, they may become lost or
stolen. The Campus Children’s Center and its staff are not responsible for those items.
8) I/We understand that electronic devices may be confiscated if questionable material or behavior is
reported or suspected. Parents will be required to discuss the situation with staff and possibly
search the device before it is returned to them. _____________Initials
9) I understand that in the event that my child is injured while engaged in camp activities my
insurance is primary and the camp insurance is supplemental.
Parent/Guardian Signature:_________________________________ Date:_______
Parent/Guardian Signature:_________________________________ Date:_______
This registration agreement must accompany your enrollment form at the time of sign up.
No enrollment form will be accepted without a signed registration agreement.
Breaking the registration agreement may result in disenrollment.
Child’s Name:________________________________ DOB________ Shoe Size:________
**Please be sure to complete all sections of this page**
Grade Completing in June 2015: __________
OGS Badge
If you have an OGS Badge, and are enrolling at CCC, we can have it activated for the front door of Building #4. Please put
your badge number here-- it will start with a 2*
OGS Badge Number 2*_______________________
Name as it appears on badge____________________________________________
OGS Badge Number 2*_______________________
Name as it appears on badge____________________________________________
T-Shirt Size
Please circle the one most appropriate size for your child
Child sizes
Adult sizes
Are there any issues or concerns of which we need to be made aware? _____yes _____no
Please remember, if your child requires medication to be successful in school, they need to continue on those medications while at
How did you hear about us? Please be as specific as possible!
Movie Choice
On rainy days we may choose to go to the movies. Please circle the movie rating you will allow your child to view. Please take
into consideration that due to the number of children participating in our camp we are unable to contact every parent when
deciding which movie your child can see. Please note that PG is the lowest rating because G movies are not always available.
If left blank, we will only allow your child to see PG movies. Circle one of the following choices:
Campus Children's Center, Inc.
Summer Fling 2015
Behavior Agreement
Child’s Name _____________________________________________________ DOB ___________________________
Parent/Guardian__________________________________________________ Phone__________________________
trying new activities.
fellow campers towards creating an environment that is
safe and welcoming for each of us.
work with my counselors and fellow campers to set expectations for our group behavior and
will adhere to these expectations.
or staff, either physically or
emotionally is grounds for dismissal from camp.
will remain respectful of my fellow campers and staff; refraining from any behavior that could be
interpreted as demeaning or harassing.
are always ready to listen and assist if there is a problem. I understand that my counselors
need and want to help but can only do so if I am willing to share any concerns that I have with them.
language will not be accepted.
will be happy to allow me to use the phone and will pass on any urgent messages from home.
campers and staff.
try to leave any
video games, music systems, laptops, or other digital media at home. I might however, bring
a good book! (This may be required if continued use becomes disruptive.)
any kind while at camp.
We have read and agree to the above behavior agreement and understand that not following these
policies may result in disciplinary actions including dismissal from camp.
Camper’s signature
Parent’s signature
PO Box 3701
Albany, NY 12203
Dear Parents and Guardians,
As part of our marketing activities we periodically do a variety of photographing. These pictures will be used as part of our marketing
activities including but not limited to use on YouTube, our web page and facebook pages. In order for your child to participate, please sign
the attached permission slip. If we do not receive this form, your child will NOT be photographed.
It may be helpful for you to know that the photo release agreement states that you are giving permission for us to use video of your child
without payment. We need a separate agreement for each individual, additional forms are available in the office.
Thank you for your support in this project.
Web Site and/or Brochure, Etc. Marketing Permission
For good and valuable consideration, receipt of which is hereby acknowledged, I, the parent/ guardian of
_________________________________________ hereby consent and agree that the Campus Children’s Center,
Inc. may use pictures or likenesses, recordings of voice, and/or pictures or likenesses of property of my child on
the web site, social media or in any form or manner, for any legitimate purpose, and at any time or place they
desire. I agree that I am to receive no further compensation other than already received for any further uses by
said Campus Children’s Center, Inc. or it’s sites.
This agreement to be binding on my heirs, successors, and assigns, and represents the entire agreement
between myself and the Campus Children’s Center, Inc., regarding the matters here in agreed.
Dated: _____________________
Location: Albany, NY_________
Parent or guardian signature (if child is not of legal age:
Medical Statement of Child in Childcare
To Be Completed By Licensed Physician, Physician’s Assistant or Nurse Practitioner
Name of Child:
Date of Birth:
Date of Examination:
Immunizations required for entry into day care
Medical Exemption The physical condition of the named child is such that one or more of the
immunizations would endanger life or health. Attach certification specifying the exempt immunization(s).
Diphtheria, Tetanus and Pertussis (DPT)
Diphtheria and Tetanus and acellular
Pertussis (DTaP)
Polio (IPV or OPV)
Haemophilus influenzae type B (Hib)
Pnuemococcal Conjugate (PCV) for
those born on or after 1/1/08)
Hepatitis B
Measles, Mumps and Rubella (MMR)
Varicella (also known as Chicken Pox)
1st Date
2nd Date
3rd Date
4th Date
5th Date
1st Date
2nd Date
3rd Date
4th Date
1st Date
2nd Date
3rd Date
4th Date OR 1st Date (if given
on or after 15 months of age)
1st Date
2nd Date
3rd Date
4th Date
1st Date
2nd Date
3rd Date
1st Date
2nd Date
1st Date
2nd Date
Other Immunizations may include the recommended vaccines of Rotavirus, Influenza and Hepatitis A
Type of Immunization:
Type of Immunization:
Type of Immunization:
Type of Immunization:
Type of Immunization:
Type of Immunization:
Is medication regularly taken?
(Specify drug and condition)
Is a special diet required?
(Specify diet and condition)
Are there any hearing, visual or dental conditions
requiring special attention?
Are there any medical or developmental
conditions requiring special attention?
Summary of Physical Exam
Include special recommendations to Day Care Providers
On the basis of my findings as indicated above and on my knowledge of the named child, I find that:
he/she is free from contagious and communicable disease and is able to participate in day care.
Signature of Examiner
Please Print Name
City, State, Zip