The following immunizations are required by the Department of Human services (Hep B, Hep A, Hib, DTAP, MMR, Varicella, and Polio). These shots are important for the safety of your child and all the other children in the school. Please provide a photocopy of the original record.

Child's Name______________________________ has been examined and found free of infectious and contagious disease and is physically and mentally able to participate in group activities.

Date___________________

Doctor's Signature _____________________________

*Please print this page. Return to the RCDC office with the Doctor's signature.

Immunization Form