Just Kids Medical Admission Requirements

Campus: *
Child's Name *

First Name Last Name
Medical Admission Requirement
If your child does not attend pre-kindergarten or school away from the child care operation, one of the following must be presented when your child is admitted to the child care operation or within one week of admission.
Check ONLY ONE option
1. Health Care Professional’s Statement: I have examined the above named child within the past year and find that he or she is able to take part in the day care program. (Have Health Care Professional Sign and date this form)

Option 1
2. A signed and dated copy of a health care professional’ statement is attached.

Option 2
3. 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 submit to the child care operation.

Option 3
4. Medical diagnosis and treatment conflict with the tenets and practices of a recognized organization, which I adhere to or am a member of. I have attached a signed and dated affidavit stating this.

Option 4
Name of Health Care Professional *
Address of Health Care Professional *

Street Address

Street Address Line 2

City State

Zip Code
Signature – Parent or Legal Guardian *

Clear
Date Signed *

Month Day Year
Date

Requirements for Exclusion
I have attached a signed and dated affidavit stating that I decline immunizations for reason of conscience, including religious belief, on the form described by Section 161.0041 Health and Safety Code submitted no later than the 90th day after the affidavit is notarized. I have attached a signed and dated affidavit stating that the vision or hearing screening conflicts with the tenets or practices of a church or religious denomination that I am an adherent or member of.
If Applicable: Upload signed and dated affidavit.

Cancel of

Vaccine Information
You may upload a copy of your child's most recent shot records instead of completing the immunization records on this form.

Cancel of
The following vaccines require multiple doses over time. Please provide the date your child received each dose.

Hepatitis B

Rotavirus

Diphtheria, Tetanus, Pertussis

Haemophilus Influenza Type B

Pneumococcal

Inactivated Poliovirus

Influenza

Measles, Mumps, Rubella

	Date
12-15 Months
4-6 Years

Varicella

	Date
12-15 Months
4-6 Years

Hepatitis A

	Date
12-23 Months (first dose)
Second dose

Physician or Public Health Personnel Verification
Signature or stamp of a physician or public health personnel verifying immunization information above:
Signature

Clear
Date Signed

Month Day Year
Date

Varicella (Chickenpox)
Varicella (chickenpox) vaccine is not required if your child has had chickenpox disease. If your child has had chickenpox, please complete this Statement. My child had varicella disease (chickenpox) on or about (date) blanks and does not need varicella vaccine.
Signature *

Clear
Date SIgned *

Month Day Year
Date

Additional Information Regarding Immunizations
For additional information regarding immunizations, visit the Texas Department of State Health Services website at www.dshs.state.tx.us/immunize/public.shtm.

Medical Admission Requirement