I\richigan Depaftment of Human Services Bureau of Chrldren and Adult Licensing

APPLICANT/LICENSEE INFORMATION

MEOICAL CLEARANCE REQUEST

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PLEASE
I\4AIL TO

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Adult Foster Carc {24-Ho!rCare) Child Fosler Care (24-Hour Care) Child Carc (Less Than 24'Hour Care)

L cersinq Consultant (Name

Depanmentof Huma. Serycs Bureau ofCh'ldron and Adlll L,censing

7109\r'/ S.qinaw 2d Fl@r

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Name llast.

Capacity

PATIENT INFORMATION {To be Compl.ted by Patient) (Please Prinl or Tvpe}

Fut. M'ddle. Jl.. L etc.)

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xxxxxxxxxxxxxxxxxxxxxxxx \DooAooin+ xx RELEAS OF INFORMATION Cro be Completed

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by Patient)

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to the cre facility listed above and io the

I ?uthorize the release of medical information concerning me Michigan Department of Human Seruices, Bureau of Children and Adu

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Licensrng, for the purpose of determining my suitability to provide or be assoclated with the care of ch dren/dePendenl MEDICAL INFORMATION iTo be Completed by Physician)
a ch rld/dependeFt adu[ cate *tting_ Thrs indiv'dual is, or will be, employed 'n ca; ae in iuch physicaland mental condition tnd healti it is neces,N ro esrahtish rhat thGe Drovidinq aftect the heaith or safety ola child/dependantldult and the qualitv and danner or h'she'care To assist us in lhis d6t';i.ation, you ac being asked to aGwer the tollo*ing' Hec rh,s P:rsdn

ts 6otIo adve6elv

No !,ziY3* rYesa
Fow would yo! des.nbe hepalienrs

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;;;ih, rue comne.ts

Positrve rExora'n in comments secrio. ror 6xpranatans)

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children/depe.denl adults No ohvs tlmenrat co.drtion or healh prcbem exists that would limirthe abrliiy lo rc.k with tr ar.und children/dependeni aduLts w1h da.olnd f|physrca /nentar condrtion or healrh probleo exrsrsrhat woltd not tiri! u.e abilty to work needed may b ln if .easonable 5c@mmodation Explain Commenis physi@t/mental conditio. or heairh p.oblem exEts whlch would aifect the abilit! ro wo* wiih .r around children/dependent adulis. wilh

rr wilhoot reasonable accomnodanon

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is reeded )

Comments (Please use back or lfi s aom if addnionsl

Vvould you like to be conlacted by lhe liceosing consultani rcgarding your

recommendanon?

Yes

No

Address

lsteet Number

A'l loPr-v ] qzlPA116 9/3 PA 116 AUTNORITY

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and Name

2,1 RErpo\sc_ /o'1.'a1

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will not disdminate aqainst an! l n..;rrmeFl rr Hma; seryites (DHS) 4''qorqp,ruo,d'o.qr io, @ioJ q'oup uecause or 6ce. sex Eriqo. tqe..arioralonE. , i nai.ouator -a-ri"i,,,,",o-.**,.Bce,er ...ni @,qhi -dda, .rd,, oor'Lar o?l'-t o d;\db'l'/ r' /oL need relo wrt'eadrd /a"q '4'a "c Ina4 aeAr{ an\*iLDi!hil'" 4 nPed de n/id o .ah

i i. .!,3 !.iernall\,led. .,d.l/ll4{J327

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Philr

. . ,- :, ill4-9300

Fax ?48-ii74-9309