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4100 Millersburg Road Evansville IN 47725Friends Forever
Preschool
Today’s Date_________________
Child’s Name__________________________________________________________
Are child’s immunizations current?__________________
Is child healthy and able to attend schooland participate in all activities?_____________________
Doctor comments:________________________________
______________________________________________________
Doctor’s name:_____________________________________
Doctor’s signature:________________________________
Medical FormFax: 812.867.4080
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