Appendix J: Exclusion Form
Exclusion Form
Child’s Name:_______________________________________________ Date:__________________________
Today your child was observed to have the following signs or symptoms of illness:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Based on our exclusion policy, your child is being excluded from care: yes no
If excluded, your child can return when:
The signs and symptoms are gone
The child can comfortably participate in the program
We can provide the care your child needs
When you have clearance from a medical care provider
Other: ________________________________________
Parent/guardian: ________________________________
Date: ____________ Time: _________