April 2019   
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This Week's Events
APR

25

THU
Wesley Walkers (WH)
6:00 AM to 7:45 AM
CEAB - Appointments
9:00 AM to 10:45 AM
Gathering Room
Thrive - After School Program
2:30 PM to 5:00 PM
Bridges of Hope Store - Open
5:00 PM to 7:00 PM
Chancel Choir - Rehearsal
7:00 PM
Music Room and Sanctuary
APR

26

FRI
Wesley Walkers (WH)
6:00 AM to 7:45 AM
Thrive - After School Program
2:30 PM to 5:00 PM
Bible Search

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(        )______________________