Yours

Appendix J- Exclusion Form

Health, Safety, and Nutrition · LibreTexts

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    Appendix J: 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: _________

    This page titled Appendix J- Exclusion Form was last modified on Wed, 26 Mar 2025 03:59:29 GMT and is shared under a CC BY 4.0 license and was authored, remixed, and/or curated by Jennifer Paris via source content that was edited to the style and standards of the LibreTexts platform.