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SOUTH CAROLINA DEPARTMENT OF SOCIAL SERVICES

GENERAL RECORD AND STATEMENT OF CHILDS HEALTH

FOR ADMISSION TO CHILD DAY CARE FACILITY

INSTRUCTIONS: THIS FORM IS TO BE COMPLETED FOR EACH CHILD AT THE TIME

OF ENROLLMENT IN THE CHILD DAY CARE FACILITY AND

MAINTAINED ON FILE AT THE FACILITY.

GENERAL INFORMATION: (COMPLETED BY PARENT OR GUARDIAN)

NAME OF FACILITY_______________________________ COUNTY_________________

ADDRESS________________________________________________________________

_________________________________________________ ZIP__________________

NAME OF CHILD__________________________________________________

ADDRESS________________________________________________________________

_________________________________________________ ZIP__________________

DATE OF BIRTH_________________ ENROLLMENT DATE_______________________

NAME OF PARENT OR GUARDIAN____________________________________________

NAME OF PERSON(S) RESPONSIBLE IF PARENTS ARE UNAVAILABLE________________

_______________________________________________________________________

ADDRESS________________________________________________________________

TELEPHONE NUMBER(S)___________________________________________________

FAMILY CODE WORD(S)____________________________________________________

IS CHILD CURRENTLY ENROLLED IN SCHOOL? ______YES _______NO

NAME OF FAMILY PHYSICIAN OR HEALTH RESOURCE____________________________

_______________________________________________________________________

ADDRESS________________________________________________________________

TELEPHONE NUMBER(S)___________________________________________________

OVER PLEASE: (HEALTH INFORMATION ON OTHER SIDE MUST BE COMPLETED FOR ENROLLMENT)

DSS Form 2900(Mar. 94) DC EDITION OF May 86 IS OBSOLETE

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HEALTH INFORMATION: (COMPLETED BY PARENT OR GUARDIAN) 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: ________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

CERTIFICATE OF IMMUNIZATION: _______ YES _______ NO

I CERTIFY THAT TO THE BEST OF MY KNOWLEDGE_________________________________

IS IN GOOD METNAL AND PHYSICAL HEALTH AND ABLE TO PARTICIAPTE IN THE CHILD DAY CARE PROGRAM AT__________________________________________________ .

SIGNATURE____________________________________________ DATE:___________________

(PARENT(S) OR GUARDIAN(S))

SIGNATURE____________________________________________ DATE:___________________

(DIRECTOR/OPERATOR OR STAFF DESIGNEE)

DSS Form 2900(Mar. 94) DC EDITION OF May 86 IS OBSOLETE