General Health Appraisal Form

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    Parent

    Please complete, Date & Sign

    Sunscreen/creams may be applied as requested in writing by parent unless skin is broken or bleeding.

    Sleep:Your healthcare provider recommends that all infants less than 1 year of age be placed on their back for sleep.

    I,, give permission for my child's healthcare provider to share this form and applicable attachments with my child's school, childcare, or camp. Contact information for the person to receive thisform:

    Health Care Provider

    Please complete after parent section has been completed.

    A separate medication authorization form (link)is required for medications given in school, childcare, or camp.

    A separate diet statement(link)is required for food provided at school, childcare, or camp.

    Health Care Provider

    Please complete if appropriate. This information is required by Early Head Start and Head Start Programs per the State EPSDT Schedule

    Provider Signature

    This child is healthy and may participate in all routine activities in school, childcare, or camp. Any concerns or exceptions are identified on this form.

    *The AAP recommends Well Child Visits at 2, 4, 6, 9, 12, 15, 18, 24, and 30 months, and annually after 3 years.

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    The form was created by the American Academy of Pediatrics, Colorado Chapter and Healthy Child Care Colorado to satisfy childcare and Head Start requirements in Colorado. While accepted by most schools, childcare programs and camps, this is not an official government form. Updated01/2021.