119 | P a g e
Child’s Statement of Health Status for Enrollment Children in
ECE must submit a signed and dated statement of the child’s current
health status upon admission which indicates the child’s ability
and/or limitations to participate in a regularly scheduled program
in a group of young children. Parents may use this form, or a
statement of health status with the same information as provided by
their child’s health provider. This report is to be completed by a
health care provider who has seen the child in the last twelve
months.
No later than 30 days after admission, this report or a written
verification of a scheduled appointment with a health care provider
must be given to the ECE teacher.
The ECE program may refuse to admit a child if a statement from
an approved health care professional is not submitted.
Child’s Name___________________________________________
Gender______ Birth Date_____________
Address________________________________________ City &
Zip_________________________________
Date of child’s most recent examination:_______________ Date
next visit is required:__________________
Known
allergies__________________________________________________________________________
Medications being taken and possible side
effects:______________________________________________
________________________________________________________________________________________
Prescribed
routine:_________________________________________________
Past Illnesses - Check those the child has had and give
approximate dates: Chicken Pox____________ Rubeola____________
Rubella_______________ Rheumatic Fever________ Asthma_____________
Hay Fever_____________ Diabetes_______________ Mumps_____________
Epilepsy______________ Whooping Cough________
Poliomyelitis_________ Other_________________
If tuberculin test given: Date______________
Result________________
If chest X ray taken: Date______________
Result________________
Date of screening for: Vision____________ Hearing____________
Dental____________ Developmental____________ o Was child referred
for further evaluation (circle one)? Yes / No
Surgery/Accidents/Illnesses/Chronic or Handicapping
Problems:___________________________________
________________________________________________________________________________________
Describe any physical condition requiring special attention by
staff:_________________________________
_________________________________________________________________________________________
This child is ______ is not ______ physically and/or emotionally
able to participate in the DPS ECE program.
Comments:_______________________________________________________________________________
Health Provider Name________________________________________
Phone_________________________
Address_________________________________________ City &
Zip________________________________
Signature of licensed physician or licensed nurse practitioner
Date
120 | P a g e
Declaración del Estado de Salud Del Niño Para Su Inscripción
Los niños en ECE o Educación de Primera Infancia deben entregar
una declaración firmada y fechada del actual estado de salud del
niño para ser admitidos al programa que indique la capacidad y/o
limitaciones del niño para participar de un programa regularmente
programado en un grupo de niños pequeños. Este informe debe ser
completado por un médico con licencia o una enfermera profesional
con licencia que ha visto al niño en los últimos doce meses.
A más tardar 30 días después de la admisión, a la maestra de ECE
debe darse este informe o una verificación escrita de una cita
programada con un proveedor de cuidado de salud. El programa de
Educación de Primera Infancia o ECE puede rehusar admitir a
un niño si no se entrega una declaración de un aprobado
profesional de cuidado de salud.
Nombre del niño__________________________________ Género______
Fecha de nacimiento___________
Domicilio________________________________________ Ciudad y
Código Postal _____________________
Fecha del más reciente examen del niño:___________ Fecha de la
próxima visita se requiere:___________
Alergias
conocidas_______________________________________________________________________
Medicinas que se están tomando y los posibles efectos
secundarios:________________________________
_________________________________________________________________________________________
Rutina
prescrita:______________________________________________________
Enfermedades pasadas – Marcar aquéllas que el niño ha tenido y
dar fechas aproximadas: Sarampión____________ Varicela____________
Rubéola_______________ Fiebre reumática________ Asma______________
Fiebre del heno_________ Diabetes_______________
Paperas____________ Epilepsia______________ Tos ferina________
Poliomielitis_________ Otra_________________
Si se da la prueba de tuberculina: Fecha______________
Resultado________________
Si se toma la radiografía del pecho: Fecha______________
Resultado________________
Fecha del examen preliminar de: Visión____________
Auditivo____________ Dental____________ Desarrollo____________ o
¿Se recomendó al niño para una evaluación adicional (marque uno)?
Si / no
Cirugía/Accidentes/Enfermedades/Crónicas o de Problemas de
deficiencias motoras, físicas o mentales:
__________________________________________________________________________________________
Describir cualquier condición física que requiere atención
especial del personal: ______________________
__________________________________________________________________________________________
Este niño puede ______ no puede ______ físicamente y/o
emocionalmente participar del programa de Educación de Primera
Infancia o ECE de DPS o las Escuelas Públicas de Denver.
Comentarios:
_____________________________________________________________________________
Nombre del Proveedor de Salud_______________________________
Teléfono________________________
Dirección_________________________________________ Ciudad y Código
Postal____________________
Firma del médico con licencia o la enfermera profesional con
licencia Fecha
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