Childcare Provider Medical Clearance Form
This form is used to confirm that a caregiver is medically fit to work with children. Please complete all required sections accurately.
Caregiver Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Job Role / Applied Position
*
Current Medical Conditions or Restrictions
*
Current Medications
*
Physician / Healthcare Provider Name
*
Medical Clearance Status
*
Cleared to work with children
Cleared with restrictions
Not cleared to work with children
Medical Clearance Statement or Declaration (to be completed by the healthcare provider)
*
Submit
Should be Empty: