Application Form

(55 PA CODE §§3270.131, 3280.131 AND 3290.131)

    Undertaking

    I authorize the child care staff and my child’s health professional to communicate directly if needed to clarify information on this form about my child.​

    DO NOT OMIT ANY INFORMATION

    ​This form may be updated by a health professional. Initial and date any new data. The child care facility needs a copy of the form.
    Max file size: 20MB
    Note below if the results of vision, hearing or lead screenings were abnormal. If the screening was abnormal, provide the date the screening was completed and information about referrals, implications or actions recommended for the childcare facility.

    RECORD DATES OF IMMUNIZATIONS BELOW OR ATTACH A PHOTOCOPY OF THE CHILD’S IMMUNIZATION RECORD

    Parents may write immunization dates; health professional should verify and complete all data.












    Max file size: 20MB
    Signature of physician, CRNP or physician’s assistant

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