September 2018  
SMTWTFS
      1
2345678
9101112131415
16171819202122
23242526272829
30    
This Week's Events
SEP

21

FRI
SWNS - Final SALE DAY for PIZZA Fundraiser
All Orders must be turned in today by NOON to SWNS for Pizza Fundraiser.
Wesley Walkers (WH)
6:00 AM to 7:45 AM
Thrive - After School Program
2:30 PM to 5:00 PM
Bible Search
SWNS - HEALTH FORM

Health Check-up Form

Susanna Wesley Nursery School

601 Main Street

Mt. Vernon, IN   47620

Fax # (812)838-2643

 

Child’s Name_________________________________________________________ Date____/____/________

 

1.  This child was examined and is in good health.  He/She is free from physical limitations and may participate in all activities without restrictions.           YES         NO (Please explain)__________________________________________

 

___________________________________________________________________________________________________________

2.  His/Her immunizations are current.      YES       NO (If no, which one(s) are not up to date for his/her age?       ___________________________________________________________________________________________________________

 

3. Has he/she been exposed to any communicable diseases at this time?       YES       NO

 

4. Additional remarks ____________________________________________________________

 

Signature of Physician___________________________________

 

Printed name of Physician____________________________________  Phone(        )______________________