Ill. Admin. Code tit. 77 , U, Appendix D, Form B
SAMPLE
FORM B
PHYSICIAN PERMISSION FORM
_________________________ has applied for admittance to the day care program at _________________________. Please supply the following information and also give written permission for ________________________________ to participate in the activity program.
Physical Limitations ______________________________________________
______________________________________________________________
Degree of activity ________________________________________________
______________________________________________________________
Can day care resident be involved in activities outside of the facility
(in the community)? _________________________________________________
Has _________________________ been evaluated within the last 30 days and found to be free of communicable and infectious disease? __________________________________
Medications and/or treatments and diet needed by day care resident during the period of time spent in the facility. ________________________________________________________
_________________________________________________________________
_________________________________________________________________
Can day care resident take own medication? ____________________________
Allergies ________________________________________________________
_______________________________________________________________
Date: __________________ Signature of Physician: ________________________
Ill. Admin. Code tit. 77 , U, Appendix D, Form B