Ill. Admin. Code tit. 77, pt. 330, subpt. R, app C, form B
SAMPLE | ||||||||||||||
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, pt. 330, subpt. R, app C, form B