Childcare Provider Medical Clearance Form
Childcare Provider Medical Clearance Form – Please complete this form to confirm your ability to safely perform childcare duties.
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Are you able to safely perform all essential childcare duties and responsibilities?
*
Yes
No
If there are any restrictions or accommodations needed, please specify.
Medical Provider or Clinic Name
*
Medical Provider or Clinic Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Medical Clearance
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Medical Provider Signature
*
Submit
Submit
Should be Empty: