Appendix J: Exclusion Form

Exclusion Form

Child’s Name:_______________________________________________   Date:__________________________

Today your child was observed to have the following signs or symptoms of illness:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Based on our exclusion policy, your child is being excluded from care:         yes      no

If excluded, your child can return when:

The signs and symptoms are gone

The child can comfortably participate in the program

We can provide the care your child needs

When you have clearance from a medical care provider

Other: ________________________________________

Parent/guardian: ________________________________

Date: ____________      Time: _________