South Carolina Department of Social Services Child Care Regulatory Services
GENERAL RECORD AND STATEMENT OF CHILD’S HEALTH FOR ADMISSION TO CHILD CARE FACILITY
This form is to be completed for each child at the time of enrollment in the child care facility, updated as needed when changes occur, and maintained on file at the facility.
General Information
(To be completed by parent or guardian)
Facility
County
Address
City, State, Zip
Child's Name
Date of Birth
Enrollment Date
Address
City
State
Zip
Parent/Guardian's Full Name
Home Phone
Work Phone
Other Phone
Parent/Guardian's Full Name
Home Phone
Work Phone
Other Phone
You must have two individuals who have the authority to obtain emergency medical treatment for the child.
Emergency Contact Full Name
Relationship
Address
City
State
Zip
Phone Number(s)
Family Code Word(s)
Emergency Contact Full Name
Relationship
Address
City
State
Zip
Phone Number(s)
Family Code Word(s)
Child is currently enrolled in school. (5K up to 6 Years)
My child will regularly attend this facility
FROM
TO
If child is drop-in, indicate hours of care.
FROM
TO
Check all days child will regularly attend this facility.
Mon
Tue
Wed
Thur
Fri
Sat
Sun
Check all meal child will receive daily.
None
Breakfast
Morning Snack
Lunch
Afternoon Snack
Dinner
Evening Snack
Health Information
(To be completed by parent or guardian)
Family Physician or Health Resource
Phone Number
Address
City
State
Zip
Emergency Care Provider
Phone Number
Address
City
State
Zip
Dental Care Provider
Phone Number
Address
City
State
Zip
Health Insurance Provider
Certificate of Immunization
Yes
No
N/A
Please Explain
My child has the following health conditions such as allergies, asthma, diabetes, epilepsy, etc., and/or takes the following medications on a regular basis:
Additional Comments:
I certify that to the best of my knowledge
is in good mental and physical health and able to participate in the child care program at
Signature
Signature