Duty Day Participant Name: _______________________________________________________________________________ Date of ______________________________________________________________________________ Child’s name: ________________________________________________________________________________ Duty Day participants and Volunteers are required to show evidence of the following information: 1. MMR (one lifetime dose of each) 2. Diphtheria and Tetanus (once every 10 years) 3. Pertussis (one dose) 4. A one step TB skin test (or x-ray) or test Test X- im- skin Measles Date Measles) Skin (if tests Tetanus (Lockjaw) Diphtheria Rubella Results Pertussis positive) Other (German Comments, TB munizations Ray (year/ Physician’s Signature Physician’s Address Telephone No. ( ) Date
Duty Day Participant Name: _______________________________________________________________________________ Date of ______________________________________________________________________________ Child’s name: ________________________________________________________________________________ Duty Day participants and Volunteers are required to show evidence of the following information: 1. MMR (one lifetime dose of each) 2. Diphtheria and Tetanus (once every 10 years) 3. Pertussis (one dose) 4. A one step TB skin test (or x-ray) Date (year/ Diphtheria Pertussis Tetanus (Lockjaw) Measles Rubella (German Measles) TB Skin Test Results X- Ray (if skin test positive) Comments, Other im- munizations or tests Physician’s Signature Physician’s Address Telephone No. ( ) Date
Oriole_Registration_Package_2016_2017.docx