Rev. 2/19/20 FSS-F25
MEDICAL VERIFICATION OF RESPITE FORM
(To be completed by Medical Professional)
Child’s Name: DOB:
Parent’s/Guardian’s Name: Phone #:
Address:
This family may be eligible for Head Start/Early Head Start Full Day Services. The parent/guardian
listed above has indicated that there are medical reasons that they are unable to care for the child for
extended periods of time and therefore require some respite services.
Please indicate the parent’s condition and impact on their ability to care for their infant or
preschool age child:
This condition will be resolved:
Indefinite (no known end date at this time)
Date of anticipated resolution________________________________
Date this form was completed: _________________________________________
Doctor’s Name: _________________________________________________
Address: _______________________________________________________
Telephone Number: ______________________________________________
Signature and/or Stamp of Medical Practitioner: ________________________________
STAFF USE ONLY
Child’s Name: ______________________________________
DOB: ____________________________
Date Received: _____________________________
