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)

Name of Facility: County:

Address:

Home Phone: Work Phone: Other Phone:

You must have two individuals who have the authority to obtain emergency medical treatment for the child.

1. Person responsible if parent/guardian unavailable for emergency medical services:

Address:

Telephone Number(s): Family Code Word(s):

2. Person responsible if parent/guardian unavailable for emergency medical services:

Address:

Telephone Number(s): Family Code Word(s):

Is Child currently enrolled in school? (5K up to 6 years old)

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Check all meals Child will receive daily:

Meals are not offered

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Breakfast

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Morning Snack

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Lunch

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Afternoon Snack

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Dinner

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Evening Snack

HEALTH INFORMATION: (to be completed by Parent or Guardian)

Family Physician or Health Resource:

Emergency Care Provider:

DSS Form 2900 (MAR 10) Edition of OCT 07 is obsolete.

City, State, Zip

City, State, Zip

Street Address City, State, Zip Telephone

Emergency Facility Name

Street Address City, State, Zip Telephone

Horry County