SAMPLE | |||||||||||
PHYSICIAN PERMISSION FORM | |||||||||||
___________________________________has applied for admittance to the day care program at _____________________________. Please supply the following information and also give written permission for _____________________ to participate in the activity program. | |||||||||||
Physical Limitations | ________________________________ | ||||||||||
_________________________________________ | |||||||||||
Degree of activity | ________________________________ | ||||||||||
_________________________________________ | |||||||||||
Can day care resident be involved in activities outside of the facility (in | |||||||||||
the community)? | _________________________________________ | ||||||||||
Has ________________________been evaluated within the last 30 days | |||||||||||
and found to be free of communicable and infectious disease? | |||||||||||
_________________________________________ | |||||||||||
_________________________________________ | |||||||||||
Medications and/or treatments and diet needed by day care resident | |||||||||||
during the period of time spent in the facility. | |||||||||||
_________________________________________ | |||||||||||
_________________________________________ | |||||||||||
Can day care resident take own medication? | _______________________ | ||||||||||
Allergies | _________________________________________ | ||||||||||
Date | _______________ | Signature of Physician | _______________ |
Ill. Admin. Code tit. 77, pt. 350, subpt. Q, app D, form B