Health Check-up Form

Susanna Wesley Nursery School

601 Main Street

Mt. Vernon, IN   47620

Fax # (812)838-2643

 

Child’s Name_______________________________________________    Date of Exam:____/____/________

 

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

            If YES, which one? _____________________________________________________________________

 

4. Additional remarks _________________________________________________________________________

 

Signature of Physician___________________________________

 

Printed name of Physician________________________________  Phone__________________________

 

 

 
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This Week's Events
APR

19

MON
Wesley Walkers (WH)
6:00 AM to 7:45 AM
APR

20

TUE
Wesley Walkers (WH)
6:00 AM to 7:45 AM
Bridges of Hope Store - Open
9:00 AM to 2:00 PM
Store is located at Door G, just off College Ave between 6th and 7th Streets
STAFF MEETING
9:00 AM to 10:00 AM
Meeting in the Gathering Room
Bible Study w/ Pastor Christopher
10:00 AM
Meet in Foundations SS Classroom WH
APR

21

WED
Wesley Walkers (WH)
6:00 AM to 7:45 AM
APR

22

THU
Wesley Walkers (WH)
6:00 AM to 7:45 AM
CEAB - Appointments
9:00 AM to 10:45 AM
Gathering Room
Chancel Choir - Rehearsal
7:00 PM
Music Room and Sanctuary
APR

23

FRI
Wesley Walkers (WH)
6:00 AM to 7:45 AM
APR

24

SAT
Bridges of Hope Store - Open
9:00 AM to 2:00 PM
Store is located at Door G, just off College Street between 6th & 7th Streets.
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