Rockland Montessori School

Dear Physician:

The following child is enrolled in an early childhood program licensed by the Department of Early Education and Care.

Department regulations require at the time of admission a written statement from a physician as evidence of each

child's annual physical examination, immunizations and lead screening in accordance with Department of Public

Health's recommended schedules. A prompt response is appreciated.

Name of Child:____________________________________________________Date of Birth_______________________

Address:_______________________________________________________________Phone #_____________________

Name of Parents:______________________________________________________________________________________

Address:_____________________________________________________________________________________________

Date of Examination of Child:________________________________________________________________________

What is your opinion concerning the child's general health and appearance:

_____________________________________________________________________________________________________

Has this child been screened for lead poisoning? Yes_____ No_____

If yes, date screened:_________________________________________________________________________________

Does this child have any disabilities or chronic medical problems (allergies, limited vision, etc) which

require special consideration or care by the day care provider? If so, please detail below:

______________________________________________________________________________________________________

Physician's Signature:_________________________________________________________Date:__________________

Comments:_____________________________________________________________________________________________

Please return to:

Rockland Montessori Academy
122 Maple St
Malden, MA 02148
781-321-3339