RED APPLE PRIVATE SCHOOL & CHILD CARE
7605 Bissonnet  Houston, Texas 77074    (713) 771-7913

CERTIFICATE OF HEALTH AND IMMUNIZATION RECORD

Child’s Name	_________________________________________	Birthdate  _______________
Home Address_________________________________________	Phone  _________________
Parent’s Name	 _________________________________________________________________	
Name of Physician  ______________________________________Phone  _________________

Required Immunizations:		Date		Date		 Date		Booster	
DTP Dta/ DT			______________________________________________________
Hib				______________________________________________________
OPV/IPV			______________________________________________________
MMR				______________________________________________________
Hep A				______________________________________________________
Hep B				______________________________________________________
Tuberculin (TB) (Neg/Pos)	______________________________________________________
Varicella (Chickenpox)	______________________________________________________

1. Are there any restrictions on normal physical activities indicated:
   Yes ____No____ If so, specify___________________________________________________
2. Does the child have any chronic medical condition necessitating dietary supplements or 
    restrictions, medications, or avoidance of allergies?
   Yes____No____ If so, specify ___________________________________________________
3. Special Attention Required _____________________________________________________
_____________________________________________________________________________

The above named child is now free of any infectious or contagious diseases and has my permission to attend school.  Insofar as immunizations, this child is medically (up to date) (not up to date).  If not up to date now, I expect this can be made up in _____ months.  Comments: _____________________________________________________________________________.

Date_________________	Physician’s Signature ____________________________________

If this form is not signed by a licensed physician, check boxes below and sign.

____ I certify that my child is enrolled in a regular medical program and has been examined by a
         doctor in the last 12 months.
____ I certify that a current immunization record is on file at the school by child attends.
____ I certify that vaccination or immunization is against my family’s religion and a statement to
         that effect will be provided on church letterhead within 30 days.

Date_____________			Parent’s Signature_________________________________

Parents:  If your child has been examined by a licensed physician within the past 12 months this form does not require a physician’s signature initially, but will be required annually thereafter.