Medical Records & Allergies Form

Bethany Lutheran Child Development Center

10101 Walnut Hill Lane Dallas, Texas 75238

214-348-9691

cdc@bethany.net www.bethanycdc.net
Statement of Medical Eligibility
Child's Name
DOB
ADMISSION REQUIREMENT: One of the following must be presented when your child is admitted to the facility or within one week of admission. Check to indicate the option you select

Attach the current (within the last 12 months) immunization record with a healthcare providers signature or stamp certifying that the child is able to attend Bethany CDC.
Upload Shot Records

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OR

If medical diagnosis and treatment and/or immunization testing conflict with your religious beliefs, you must sign an affidavit to that effect and attach it to this form. If immunization would be injurious to your child or family, you must obtain a certificate (signed by a heath care professional) to that effect and attach it to this form.
Upload Affidavit

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Name/address/phone of health care professional
Signature

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Allergy and Pre-Existing Condition Release
List all conditions, such as allergies, existing illness, and previous serious illness and injuries during the past 12 months as well as medication prescribed for long-term continuous use of which staff should be aware of to properly care for your child. (Please enter NA if none exist.)

***If your child has a FOOD ALLERGY you are required to complete an Emergency Food Allergy Plan, as per the State of Texas***
I hereby release, discharge and/or indemnify both Bethany Lutheran Church and its Child Development Center, their employees, associated parents, substitute teachers and volunteers against any claim by or on behalf of the child enrolled in Bethany Lutheran Church Child Development Center as a result of any contact with a peanut product or other substance or food product that might cause a severe allergic reaction.
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Statement of Medical Eligibility