Mandatory Health Screening Agreement

Date: _________________	Center Name:__________________

Parents(s) /Guardian: _______________________________________

Name of the child:  _________________________________________

To: Department of Human Services Bureau of Children and Adult Licensing:

 I, _______________________, am requesting that my child attend 
           Parent / Guardian Name 
 Matrix Head Start. I have not obtained a physical for my child, but I will 

do so by :  ________________________________________________.
                 Date must be 20 days from today’s date 
    
I understand that providing the completed Health Appraisal form is part of my responsibility as a parent. I agree to work with my Family Advocate to achieve the goal of obtaining the Health Appraisal. I understand that if I do not provide proof of a Health Appraisal by the above date my child is at risk of losing his/her slot with no guarantee that the slot will be available to return. 

I, ______________________________________________________,
   Staff Signature and title 
have checked the MCIR data base. The child’s immunization status is

  _______________________________________________________.
    Fill in immunization status

I also informed the parent/guardian of the child’s immunization status.

If you have any health related questions or need assistance, you may 

contact the Health Component @ (313) 962-5255.

_________________________	                        ________________________
Parent/Guardian Signature			         Date signed

_________________________________		        _________________________
Matrix Head Start Staff Signature			        Date signed

_________________________________		        __________________________
Center Manager Signature                                                  Date signed

•	Original form to be placed in childs file.
•	A copy of this form must be given to the parent.

Health & Human Services

US Department of

Funded by the

I

Matrix Head Start

1400 Woodbridge

Detroit, Michigan

48207-3110

p. 313.962.5255

f. 313.962.5253