25: Appendix J- Exclusion Form

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Appendix J: 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: _________