City of Long Beach s1

City of Long Beach

City Council City Manager Len Torres, President Jack Schnirman Anthony Eramo, Vice President Youth and Family Services Chumi Diamond Johanna Mathieson-Ellmer Scott J. Mandel Anissa D. Moore

CITY OF LONG BEACH – MEDICAL RELEASE FORM N.Y.S. Dept. Social Services

Check One: ____ After School (____West ____Lido) ____Morning Care (____West ____Lido)

____ Sandbox ____Daycare at Magnolia ____YFS Camp ____Spots For Tots

To Be Completed By Physician, Physician’s Assistant or Nurse Practitioner

Name Date of Birth Date of Exam

- IMMUNIZATIONS - If one or more of the required medical immunizations is deemed detrimental to this child’s health, attach certificate specifying which immunization(s) and complete and sign medical exemption statement on back of form

Include All Dates Other Immunizations 1st 2nd 3rd Booster Booster Type Date / / / / / / / / / / DPT / / 1st 2nd 3rd Booster Booster Type Date ORAL POLIO / / / / / / / / / / / / 1st 2nd 3rd 4th Type Date / / / / Hib(conjugate / / / / / / preferred) 1st 2nd 3rd Hepatitis B / / / / / / 1st 2nd MMR / / / / - TESTS - Tuberculin Test Lead Screening Pos Neg Pos Neg ____/____/____ Date _____/_____/_____ Results Specify Date If positive, attach physician’s statement documenting treatment and follow-up. Attach statement of lead screening. HEALTH SPECIFICS Comments: ______Yes No Are there allergies? (Specify) ______Is medication regularly taken? ______Yes No (Specify drug and condition) ______Is a special diet required? ______Yes No (Specify diet and condition) ______Are there any hearing, visual or dental ______Yes No conditions requiring special attention? ______Are there any medical or developmental ______Yes No conditions requiring special attention? ______

PHYSICIAN’S REPORT:

HEART:______BLOOD PRESSURE:______HEIGHT:______WEIGHT:______LUNGS:_____

NERVOUS SYSTEM:______ORTHO-PEDIC-EXTREMETIES:______SCOLIOSIS, ETC:______

SPEECH:______THYROID:______TONSILS:______RECENT OPERATIONS:______

RESTRICTIONS:______IS CHILD ABLE TO PARTICIPATE IN ALL PHYSICAL ACTIVITIES? If not explain: ______

ANEMIA:______ASTHMA/ALLERGY:______CHICKEN POX:______

DIABETES:______EAR CONDITIONS:______EPILEPSY:______

FREQUENT SORE THROATS:______PNEUMONIA:______NEPHRITIS:______

RHEUMATIC FEVER:______SCARLET FEVER:______WHOOPING COUGH:______

On the basis of my findings as indicated above and on my knowledge of the above named child, I find that: (s)he is free from contagious and communicable disease Yes No

______Signature of Examiner Address

______Name (please print) City, State, Zip

- MEDICAL EXEMPTIONS -

The physical condition of the above named child is such that immunization would endanger life or health. ------Physician’s Signature Date

X______/_____/_____

For further information contact: YOUTH AND FAMILY SERVICES at 431-1035 650 Magnolia Blvd., Long Beach, N.Y. 11561 FAX# 431-5577